Problem-based Behavioral Science and Psychiatry

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Problem-Based Behavioral Science and Psychiatry

Anthony Guerrero · Melissa Piasecki Editors

Problem-Based Behavioral Science and Psychiatry

Foreword by Richard T. Kasuya

123

Editors Anthony Guerrero University of Hawai‘i John A. Burns School of Medicine Honolulu, HI USA [email protected]

ISBN: 978-0-387-77483-1

Melissa Piasecki University of Nevada School of Medicine Reno, NV USA [email protected]

e-ISBN: 978-0-387-78585-1

Library of Congress Control Number: 2008922505 c 2008 Springer Science+Business Media, LLC All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper 9 8 7 6 5 4 3 2 1 springer.com

We dedicate this book to our parents, with love. Celina and Reuben Guerrero Joan and Leo Piasecki

Foreword

Learning behavioral science is an important part of becoming physicians. More and more, professional and accrediting organizations are explicitly endorsing the necessity of physicians being skilled and well trained in these areas. Physicians themselves are increasingly aware of the importance of behavioral health and psychiatric issues in their practices. Whether one intends to practice in a primary care or subspecialty area, an appreciation of behavioral health issues and basic principles of psychiatry is critically necessary. In addition to topics that are more specific to the practice of psychiatry, the authors of this textbook have chosen to cover a range of topics important to all aspects of clinical medicine, including culture, violence, physician–patient relationships, adherence and substance abuse. Almost any practicing physician will admit that effectively addressing these types of behavioral issues is among the more challenging of the tasks they face. Teaching and learning about psychiatry and behavioral sciences can be difficult. Basic textbooks do not easily connect their lessons with the complexity of clinical reality. Students cannot easily find the clinical importance from classroom lectures. Even clinical clerkships in psychiatry have difficulty exposing students to the breadth of clinical experiences they need to learn about. This long overdue book holds the promise of becoming a solution to these challenges. The study of psychiatry and the behavioral sciences is perfectly matched with the problem-based learning methods utilized in this book. Problem-based learning (PBL) is a widely utilized approach to learning that involves the detailed study of patient cases, with a primary goal of identifying topics for self-study relevant to the cases. This approach helps students find meaning in learning a wide variety of topics and provides an opportunity to apply new knowledge to clinical situations. Through understanding the cases, they learn psychiatry. For those familiar with the PBL process, this book offers a welcome resource in the area of behavioral sciences and psychiatry. Students are sometimes reluctant to vigorously pursue a study of behavioral issues. They often cite a difficulty in finding reliable, evidence-based resources for their independent learning. Unlike the biological and clinical sciences, where there are scores of readily available textbooks, review articles and web-based resources, students often report frustration with the relative dearth of medical student-friendly resources in the behavioral sciences. This vii

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Foreword

book represents a significant addition to student learning resources in behavioral health and should become a familiar and well-worn companion to students in PBL environments. For those new to the PBL process, this book will also serve as a useful guide to approaching clinical problems. By working through the case studies in this book, the reader will not only be able to learn important material related to psychiatry and the behavioral sciences but also develop a systematic approach to life-long learning that will serve them well in their clerkships and beyond. In addition to providing opportunities to work through clinical vignettes in a problem-based learning format, the authors incorporate other useful and practical learning tools such as mechanistic case diagramming and the bio-psycho-socialcultural-spiritual formulation. In the long term, readers will benefit as much from these exercises as they will from learning the content within the pages of this book. The authors have also incorporated content areas for the United States Medical Licensing Examinations, making this textbook relevant for preparation and review for these examinations. So, in many ways, this book represents a learning tool as much as a content resource. I am also particularly encouraged to see that a number of the contributors to this book are themselves graduates of PBL medical schools. Their experiences should provide them with a unique and valuable perspective in what they have chosen to offer in the pages that follow. Readers will find the methodology and approaches offered in this book to be refreshing and educationally rewarding. I hope that this text will prove to be the first of a number of books that skillfully and thoughtfully blend authoritative content with effective problem-based learning exercises. Director, Office of Medical Education Professor of Medicine School of Medicine University of Hawai‘i at M¯anoa

Richard T. Kasuya, M.D., M.S.Ed. John A. Burns

Contents

Part I Introduction 1 How to Use This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anthony P.S. Guerrero, Melissa Piasecki, and Nathanael W. Cardon

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Part II Human Behavior 2 Childhood Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Maya Strange and Andrea Sorensen 3 Effects of Experience on Brain Development . . . . . . . . . . . . . . . . . . . . . . . 31 Jeffrey Raskin, Whitney Waldroup, Nikhil Majumdar, and Melissa Piasecki 4 Learning Principles of Human Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . 49 David O. Antonuccio and Amber Hayes 5 Sexuality Throughout the Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Kevin Allen Mack and Anthony P.S. Guerrero 6 Adaptation and Coping in a Medical Setting . . . . . . . . . . . . . . . . . . . . . . . 77 Maria-Christina Stewart 7 Violence and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Jeanelle J. Sugimoto and Anthony P.S. Guerrero Part III Healthcare Principles 8 The Physician–Patient Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 My Kha and Melissa Piasecki ix

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Contents

9 Ethics and Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Jacob Doris and Marin Gillis 10 Adherence in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Maxwell Takai Frank and Eriko Takai Frank 11 Stress and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Michael K. Daines and Nikhil Majumdar 12 Health Care 101 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 David C. Fiore and Jason P. Crawford 13 Stigma and Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 Barbara Kohlenberg, Melanie Watkins and Lindsay Fletcher 14 Culture, Ethnicity, and Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Anthony P.S. Guerrero 15 Quantitative Measures in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 M. Anand Samtani, Earl S. Hishinuma, and Deborah A. Goebert 16 Death, Dying, and End-of-Life Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Lori Murayama-Sung and Iqbal Ahmed Part IV Behavioral Neuroscience and Clinical Psychiatry 17 Basic Principles of Evaluation: Interviewing, Mental Status Examination, Differential Diagnosis, and Treatment Planning . . . . . . . 231 Anthony P.S. Guerrero, Daniel A. Alicata, and Nathanael W. Cardon 18 Disorders of Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Erika Ryst and Jeremy Matuszak 19 Substance Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 William F. Haning III and Anthony P.S. Guerrero 20 Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Steven J. Zuchowski and Ryan Ley 21 Mood Disorders and Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Mireille Anawati 22 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Mireille Anawati

Contents

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23 Somatoform Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Jonah Shull and Catherine McCarthy 24 Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 Latha Pai, Melissa Piasecki, and M. Nathan Mason 25 Cognitive Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 Russ S. Muramatsu and Junji Takeshita 26 Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 Ole J. Thienhaus and Nathanael W. Cardon 27 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393 Hy Gia Park and Cathy K. Bell 28 Sexual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Crissa R. Draper, Nikhil Majumdar, William T. O’Donohue, and Melissa Piasecki 29 Other Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Anthony P.S. Guerrero Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

Contributors

Iqbal Ahmed, M.D., FRCPsych (UK) Professor of Psychiatry, University of Hawai‘i John A. Burns School of Medicine, University of Hawai‘i Daniel A. Alicata, M.D., Ph.D. Assistant Professor of Psychiatry, Psychiatry Clerkship Director, University of Hawai‘i John A. Burns School of Medicine Mireille Anawati, B.A. Fourth Year Medical Student, University of Hawai‘i John A. Burns School of Medicine David O. Antonuccio, Ph.D. Professor of Psychiatry, University of Nevada School of Medicine Cathy K. Bell, M.D. Assistant Professor of Psychiatry, Program Director Child and Adolescent Psychiatry Residency Program, University of Hawai‘i John A. Burns School of Medicine Nathanael W. Cardon, D.O. Resident in Psychiatry, University of Nevada School of Medicine Jason P. Crawford, M.D., M.P.H. Assistant Professor, Family and Community Medicine, University of Nevada School of Medicine xiii

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Contributors

Michael K. Daines, M.D. Assistant Professor of Psychiatry, University of Nevada School of Medicine Jacob Doris, M.D. Resident in Psychiatry, University of Nevada School of Medicine Crissa R. Draper, M.S. Graduate Student in Psychology, University of Nevada, Reno David C. Fiore, M.D. Associate Professor, Family and Community Medicine, University of Nevada School of Medicine Lindsay Fletcher, B.A. Graduate Student, Psychology, University of Nevada, Reno Marin Gillis, L.Ph., Ph.D. Director of Medical Humanities and Ethics, University of Nevada School of Medicine Deborah A. Goebert, Dr.P.H. Associate Professor of Psychiatry, Associate Director, Research Division, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine Anthony P.S. Guerrero, M.D. Associate Professor of Psychiatry and Pediatrics, Associate Chair for Education and Training, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine William F. Haning, III, M.D., FASAM, FAPA Associate Professor of Psychiatry, Program Director, Addiction Psychiatry/Addiction Medicine, Director, Graduate Affairs, University of Hawai‘i John A. Burns School of Medicine Amber Hayes, M.D. Resident in Family Medicine, University of Nevada School of Medicine Earl S. Hishinuma, Ph.D. Professor of Psychiatry, Associate Chair for Research, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine My Kha, M.D. Resident in Psychiatry, University of Nevada School of Medicine Barbara Kohlenberg, Ph.D. Associate Professor of Psychiatry, University of Nevada School of Medicine Ryan Ley, M.D. Resident in Psychiatry, University of Nevada School of Medicine Kevin Allen Mack, M.S., M.D. Assistant Professor, University of California, Berkeley/San Francisco

Contributors

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Nikhil Majumdar, M.D. Resident in Psychiatry, University of Nevada School of Medicine M. Nathan Mason, M.D. Resident in Psychiatry, University of Nevada School of Medicine Jeremy Matuszak, M.D. Fellow, Child Psychiatry, University of Nevada School of Medicine Catherine McCarthy, M.D. Assistant Professor, Family and Community Medicine, University of Nevada School of Medicine Russ S. Muramatsu, M.D. Fellow in Geriatric Psychiatry, University of Hawai‘i John A. Burns School of Medicine Lori Murayama-Sung, M.D. Chief Resident, General Psychiatry Program, University of Hawai‘i John A. Burns School of Medicine William O’Donahue, Ph.D. Professor in Psychology, University of Nevada, Reno Latha Pai, M.D. Resident in Psychiatry, University of Nevada School of Medicine Hy Gia Park, M.P.H., M.S. Fourth Year Medical Student, University of Hawai‘i John A. Burns School of Medicine Melissa Piasecki, M.D. Associate Professor of Psychiatry, University of Nevada School of Medicine Jeffrey Raskin Medical Student, University of Nevada School of Medicine Erika Ryst, M.D. Assistant Professor of Psychiatry, University of Nevada School of Medicine Mohan Anand Samtani, M.A. Statistician, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine Jonah Shull, M.D. Fellow, Child Psychiatry, University of Nevada School of Medicine Andrea Sorensen, M.D. Child and Adolescent Psychiatry Fellow, University of Nevada School of Medicine Maria-Christina Stewart, M.A. Department of Psychology, University of Hawai‘i, Currently a Research Fellow at the Center for Anxiety and Related, Disorders, Boston University

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Contributors

Maya Strange, M.D. Assistant Professor of Psychiatry, University of Nevada School of Medicine Jeanelle J. Sugimoto, B.S. Program Manager, Asian/Pacific Islander Youth Violence Prevention Center, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine Eriko Takai Frank, M.S.W., M.P.H. Staff Social Worker, Beth Israel Deaconess Medical Center Maxwell Takai Frank, M.D. Resident in Psychiatry, Boston University Medical Center Junji Takeshita, M.D. Associate Professor of Psychiatry, Program Director, Geriatric Psychiatry Residency Program, Associate Chair for Clinical Services, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine Ole J. Thienhaus, M.D., M.B.A. Professor and Chair of Psychiatry, University of Nevada School of Medicine Whitney Waldroup, M.D., M.P.H. University of Nevada School of Medicine Melanie Watkins, M.D. Resident in Psychiatry, University of Nevada School of Medicine Steven J. Zuchowski, M.D. Assistant Professor, University of Nevada School of Medicine

Part I

Introduction

Chapter 1

How to Use This Book Anthony P.S. Guerrero, Melissa Piasecki, and Nathanael W. Cardon

Welcome to Problem-Based Behavioral Science and Psychiatry. In this chapter, our aims are to illustrate how the problem-based learning process works so that you can apply it to the other cases in this textbook. The goals of this chapter are: 1. To provide the reader with a guided experience on “how to use this textbook” 2. To review basic principles of problem-based learning and the rationale for why this approach is used 3. To illustrate, with a sample case, the processes of (a) “Progressive disclosure” (b) Identifying facts/problems, hypotheses/differential diagnoses, additional clinical information needed, and learning issues (c) Thinking about underlying neurobiology and other physiological mechanisms to understand the signs and symptoms of a case 4. To review the more generic process of bio-psycho-social-cultural-spiritual formulation, in order to understand the various perspectives offered by patient cases Because a textbook is not the same as a patient encounter or face-to-face small group discussion, we are not claiming to represent problem-based learning (PBL) in a pure or “authentic” form (Barrows, 1986,2000). However, we hope to integrate many of the principles and potential benefits of PBL into this textbook. PBL, as described by Norman and Schmidt (1992), aims to endow learners with the skills of clinical reasoning, cooperative learning, and patient-based integration of knowledge. In its ideal form, it begins with an initial free-inquiry process, in which learners explicitly discuss hypotheses and additional lines of investigation. This is followed by a period of self-directed learning and a synthesis and application of information back to the case. The student then has an opportunity to critically evaluate the initial clinical reasoning process. Because PBL attempts to integrate information from multiple disciplines, all phases of the process emphasize attention A.P.S. Guerrero Associate Professor of Psychiatry and Pediatrics, Associate Chair for Education and Training, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine A. Guerrero, M. Piasecki (eds.), Problem-Based Behavioral Science and Psychiatry, C Springer Science+Business Media, LLC 2008

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A.P.S. Guerrero et al.

to the biological, behavioral, and populational aspects of the case. Certain articles (Guerrero, 2001; Guerrero et al., 2003) have discussed how certain learning tools can be used to ensure that beneficial PBL processes actually occur in the course of studying a case. We will illustrate these tools, including “mechanistic case diagramming,” as part of this sample case. When compared to traditional learning methods, PBL may enhance the application of concepts to clinical situations, long-term retention of knowledge, and lifelong interest in learning (Norman and Schmidt, 1992). It has been shown to improve student and faculty satisfaction and educational outcomes in numerous clinical disciplines, including family medicine, pediatrics, obstetrics, and psychiatry (Washington et al., 1999; McGrew et al., 1999; Kaufman and Mann, 1999; Curtis et al., 2001; Nalesnik et al., 2004; McParland et al., 2004). Furthermore, we believe that psychiatry and the behavioral sciences, because of the inherently integrative and holistic approaches of these subject areas, are particularly well suited for study in a PBL format (Frick, 2005; Zisook, 2005). Peters et al. (2000) reports on the longitudinal outcomes of a randomized controlled trial and concludes that the New Pathways Program at Harvard Medical School—of which PBL is one important component—improved students’ interpersonal skills and humanistic approach to patient care, with no loss in medical knowledge. We will illustrate the problem-based learning process as applied to cases in this textbook. Typically, each chapter will begin with an introductory paragraph for a case. An example has been provided below.

Case Vignette 1.1.1 Presenting Situation: Melanie Crystal Melanie Crystal is a 39-year-old woman who is the single mother of a 17-yearold boy. She was referred for psychiatric assessment at the local emergency room because a police officer on foot patrol found her crying and confused in a nearby parking lot. She is tearful and hostile. She told the screening nurse that she would kill herself “at the first opportunity.” On screening for substance use, she stated that she used “dope.” Needle marks were visible on both arms. At this point, the student will see the following sign, which is a prompt to “Proceed with the PBL process” before moving on to the remainder of the case.

Please proceed with the problem-based approach! Learning from these cases will be maximized if the student carefully digests all components of the case and engages in the clinical reasoning processes that a clinician uses to effectively evaluate and manage the case. For example, in the case above, it may be worthwhile to:

1 How to Use This Book

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1. Highlight or underline the facts. 2. Specifically identify the clinical signs and symptoms that are present, as these are likely to be the relative “endpoints” of a mechanism that must be subsequently understood. Below we show a graphical way of identifying signs and symptoms through use of boxes. Melanie Crystal is a 39-year-old woman who is the single mother of a 17year-old boy. She was referred for psychiatric assessment at the local emergency room because a police officer on foot patrol found her crying and confused in a nearby parking lot. She is tearful and hostile . She told the screening nurse that she would kill herself “at the first opportunity.” On screening for substance use, she stated that she used “dope.” Needle marks were visible on both arms. 3. Organize these findings as shown in Table 1.1 (blank samples are provided for photocopying in Appendix). 4. Use this grid to guide the clinical reasoning process that will guide further evaluation and management of the case. Obviously, there will be variations in the specific items one will choose to put under each of the columns. The main principles to follow are: 1. To develop specific hypotheses, ask the question “What are the possible mechanisms (biological or otherwise) behind the signs and symptoms present in the case?” In this text we emphasize the neurological and physiological mechanisms that are known to be associated with normal and pathological behavior. 2. Additional clinical information (“What do you want to know next?”) reflects your hypotheses and should follow a logical clinical organization. In this textbook, the use of the clinical reasoning process will prompt or answer many of the questions in the rightmost column. Each clinical case includes text coverage of the learning issues likely to be most relevant to medical student learners. Therefore, if this sample chapter were an actual textbook chapter, it might contain sections on:

r r r

The mechanisms behind abnormal mood and confusion The mechanisms of action of common illicit drugs Definitions of child abuse and neglect

Some chapters offer high-density tables and figures to illustrate mechanisms of action. Examples include: the mechanism of psychotic symptoms (see Fig. 20.1) and the mechanism of action of common substances of abuse (see Table 19.1). With an effective clinical reasoning process, the subsequent sections of the case will address items in the “what do you want to know next” column. A sample continuation of the case vignette is shown below.

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Table 1.1 Grid to guide the clinical reasoning process that will guide further evaluation and management of the case What are the facts?

What are your hypotheses?

What do you want to know next?

39-year-old woman Single mother of a 17-yearold boy Referred for psychiatric assessment at her local ER Found by police officer at a nearby parking lot

Drugs: ? Cocaine or methamphetamine ? Heroin (IV)

HPI: What exactly does she mean by “dope?” Was she having any symptoms even before using drugs? Does she have any other symptoms— disturbed sleep, disturbed appetite, hallucinations PMH: Other medical illnesses HIV test? FH: Other psychiatric illnesses SH: Can anyone else care for the 17year-old son? Exam: Vital signs (Tachycardic? Hypertensive?) Heart murmur? Mental status: 1. Speech 2. Thought process 3. Perceptions 4. Is she homicidal? Lab: urine toxicology

Crying/tearful

Other psychiatric disorders Abnormal brain activity: • Limbic system • Other places? Sadness

Confused Hostile Stated she would kill herself Used “dope” Needle marks Possible neglect of the 17year-old minor Delirium Endocarditis

What specific information would you like to learn? What are the mechanisms behind confusion and abnormal mood? Which drugs can be used intravenously? What defines neglect or abuse of a 17year-old minor?

Case Vignette 1.1.2 Continuation Ms. Crystal was uncooperative with further questioning. Attempts to reach collateral informants were unsuccessful. On examination, vital signs were as follows: temperature 100.3 ◦ F, pulse 106 per minute, blood pressure 142/88, respiratory rate 22 per minute. The remainder of the physical examination was unremarkable except for: thin appearance, poor dentition, and needle marks on her skin. Mental status


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examination was remarkable for: poor cooperation and eye contact, mumbled rapid speech, labile and tearful affect, tangential thoughts, possible auditory hallucinations, and suicidal ideations.

Please proceed with the problem-based approach!

Once again, this is the prompt to analyze the case and complete the table as shown above.

Case Vignette 1.1.3 Conclusion After admission to an inpatient unit, Ms. Crystal went to sleep and remained asleep for almost 14 hours. She was ravenously hungry and only marginally cooperative with measurements of vital signs or attempts at interview. She remained irritable and was verbally abusive to staff for the next day. Three days later, Ms. Crystal became conversant with the staff. On the fourth day she was pleasant and social. She described her history of methamphetamine dependence beginning in her twenties, with 10 years of abstinence. She stated that she stopped going to meetings and “it only took one guy” who showed her the drug at his home. She reported that as soon as she saw and “smelled” methamphetamine, she began to have intense cravings and immediately relapsed. She has used daily for the last month or so and is not sure where her adolescent son is. She thinks he will be graduating from high school “one of these days.” The case and text discussion cover core curricular material relevant to the general subject matter. For example, if the goal of the chapter were to review methamphetamine abuse and dependence (please refer to Chap. 19), the following topics may be covered: Epidemiology (including the recent epidemic, age groups affected, mortality statistics) Differential diagnosis (including mood, psychotic, and other substance disorders) Etiology and neurobiological mechanisms Clinical findings (including cognitive changes, psychotic symptoms, motor symptoms, acute and secondary drug effects, and craving) Treatment (psychosocial and pharmacological) Social, cultural, and legal factors Prognosis

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Bio-psycho-social-cultural-spiritual Model In all our teaching, we invite students to conceptualize patient problems by using a bio-psycho-social-cultural-spiritual formulation. This model is used throughout the psychiatric curriculum at the authors’ institutions. The goal of these patient formulations is to consider the complexities of patient presentations and to drive treatment planning. Formulations help explain “how did this patient get to this psychiatric state at this time?” What follows is a description of the components of the bio-psycho-social-cultural spiritual formulation (adapted from Kohlenberg and Piasecki, 2006). We have added prompts for the students to help them think about and organize clinical material. Students are encouraged to include each component in formulations. This model generally includes the following: Biological Past: Genetics:

r

Consider whether any blood relatives have had psychiatric problems, substance use problems or suicide attempts/suicides. Is there a history of close relatives who have been hospitalized for psychiatric reasons? What kind of treatments did they get, and how did they respond?

History of pregnancy and birth:

r r

Consider pregnancy variables: Was there in utero exposure to nicotine, alcohol, medications, or illicit substances? Was there anything unusual about pregnancy? Note birth complications, such as prematurity, birth trauma, or extended periods of hospitalization.

Relevant previous illnesses:

r r

Consider any history of head injury, endocrine disorders (e.g., thyroid, adrenal), seizures, malignancies, or neurological illnesses. Consider potential lasting effects of past substance use on brain functions such as cognition, affective regulation, etc.

Present: Current illnesses:

r

Identify current illnesses and any direct impact they may have on psychiatric presentation.

Medications:

r

Assess current medication regimen. Consider whether these medications have psychoactive effects (e.g., steroids, beta blockers, pain medications, benzodiazepines, serotonin-selective reuptake inhibitors, antipsychotics). Consider possible side effects of current medications. Note any noncompliance with medications.


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Substances:

r r

Consider the influence of nicotine, alcohol, and illicit drugs on current psychiatric symptoms. Consider the possible effects of substance withdrawal.

Endocrine/hormonal:

r r

Consider the impact of onset of adolescence. Consider the impact of the menstrual cycle, pregnancy, postpartum period, menopause.

Psychological Past:

r r r r r

Comment on any past history of trauma (child abuse, combat, rape, serious illness), as well as resiliency (how the patient coped with trauma, e.g., through friends, family, religion). Consider the sources of positive self-image and positive role models. Comment on the patient’s experience with loss. Comment on the patient’s quality of relationships with important figures, such as grandparents, friends, significant teachers, or significant employers. Comment on how past medical problems, substance use, or psychiatric problems impacted the patient’s development and their relevance to the patient today.

Present:

r r r r r

Describe the recent events and experiences that precipitated the admission or appointment. What are the current stressors? Do they have any symbolic meaning? Assess and comment on coping skills, defense mechanisms, presence or absence of cognitive distortions. Consider current developmental demands on the person, such as marriage, divorce, birth, children leaving home, loss, aging, etc. What stage of development is the patient at now? Is it appropriate to chronological age? What is the developmental impact of the patient’s illness?

Social

r r r r r r r

How adequate is the patient’s current support system? What is the current status of relationships with important figures? What are the possible peer influences? Consider the patient’s current housing arrangement. Comment on vocational/financial status. Comment on any relevant legal problems. Consider the role of agencies (e.g., Veteran’s Administration, Child Protective Services, Criminal Justice System) on the patient.

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Cultural

r r

Comment on cultural influences and acculturative pressures that may impact the current situation. Comment on cultural influences on understanding of illness and/or help-seeking behavior.

Spiritual

r r r

Comment on the role of spirituality in the patient’s life. Is the patient affiliated with a spiritual community of some sort? How does spirituality contribute to the patient’s ability to hope, his/her position on suicide if relevant, or his/her contact with a supportive community?

A sample formulation for Ms. Crystal would be as follows: This is a 39-year-old woman with acute psychiatric symptoms. Biological factors that contribute to her presentation include the acute effects of methamphetamine on her mood and behavior. Methamphetamine is likely also contributing to her abnormal vital signs. There is no history of current or previous medical problems, family history of substance use disorder/mental illness or current medication use. Psychologically, this patient has recently experienced a relapse. Cues for drug use included the sight and smell of the drug. She apparently lacked coping skills for resisting relapse. There is no information about recent stressors, past trauma, or relationship history. Her role as the mother of a 17-year-old has been seriously compromised but there is little information about how she perceives this. Her relationship with a man appears to be superficial and based on mutual drug use. Socially, we have little information about her employment status, housing, legal situation, or social supports. She appears to have benefited from meetings in the past and may have been lacking the social support she needed to remain abstinent prior to her relapse. Spiritually, we have little information about her history and current beliefs. In addition, we believe that both pre-clerkship behavioral science students and clerkship psychiatry students can benefit from seeing a “big-picture” graphic representation of the formulation. This graphic uses arrows to detail how one aspect of the case leads to another and ultimately results in her presenting concerns. It also shows how the biological, psychological, and social/spiritual/cultural aspects are ultimately related and suggests how all knowledge learned (including basic neurobiological mechanisms) can be used to benefit the patient in the form of specific treatments (shown as circled items, connected to the rest of the diagram using dotted arrows). An example is shown in Fig. 1.1. While it is up to the readers to decide on the degree to which such an exercise suits their learning needs, the textbook chapters will provide such diagrams on some of the cases, in order to integrate knowledge learned in the chapter and to provide closure to the case vignettes, particularly those that cover major psychiatric illnesses and symptoms (e.g., substance use disorders, mood disorders, anxiety disorders, cognitive disorders, and eating disorders). It is our hope that this feature

atypical antipsychotic

dopamine blockade

Hyperthermia Thin

Tachycardia Hypertension

Appetite suppression

Autonomic nervous system

Fig. 1.1 Sample diagram to integrate knowledge and provide closure to case vignettes

Delusions Tangentiality Hallucinations

Mood lability

Limbic system

Increased dopamine tone

Poor cortical filtering

Norepinephrine release (intoxication)

Inappropriate mesolimbic Dopamine release

Hypothalamus

Oversensitivity of brain reward systems

Intense craving

Relapse

substance abuse program ?residential

Continued methamphetamine use

Biological

Stressor?

Address family concerns e.g., child welfare

Appropriate group and individual psychotherapy

Compromised family role

Drug-using peer

Exposure to drug

Poor coping skills

Social/Cultural/Spiritual

Psychological

1 How to Use This Book 11

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of this textbook will enhance the clinical relevance of topics learned in behavioral science and clinical psychiatry and will stimulate interest in further learning about fundamental neurobiological mechanisms behind behavioral symptoms. It is now time to learn about the other specific topics in this textbook. Once again, welcome aboard, and happy learning!

Review Question 1. Problem based learning is gaining popularity in medical schools. What are three of the documented outcomes that contribute to this popularity?


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Appendix PBL Worksheet to Guide Case Studies What are the facts?


What do you want to know next? History of Present Illness:

Past Medical History:

Family History:

Social History:

Exam:

Labs:

What specific information would you like to learn about?

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References Barrows HS. A taxonomy of problem-based learning methods. Med Educ 1986;20:481–486. Barrows HS. Authentic problem-based learning. In Teaching and Learning in Medical and Surgical Education: Lessons Learned for the 21st Century. Distlehorst LH, Dunnington GL, Folse JR, eds. Mahwah, NJ: Lawrence Erlbaum Associates, 2000. Curtis JA, Indyk D, Taylor B. Successful use of problem-based learning in a third-year pediatric clerkship. Ambul Pediatr 2001;1:132–135. Frick E. Teaching somatoform disorders in a “nervous system and behaviour” course: the opportunities and limitations of problem-based learning. Educ Health (Abingdon) 2005;18(2): 246–255. Guerrero AP. Mechanistic case diagramming: a tool for problem-based learning. Acad Med 2001;76(4):385–389. Guerrero AP, Hishinuma ES, Serrano AC, Ahmed I. Use of the mechanistic case diagramming technique to teach the biopsychosocial-cultural formulation to psychiatric clerks. Acad Psychiatry 2003;27(2):88–92. Kaufman DM, Mann KV. Achievement of students in a conventional and problem-based learning (PBL) curriculum. Adv Health Sci Educ Theory Pract 1999;4(3):245–260. Kohlenberg B, Piasecki M. Bio Psycho Social Spiritual Model, personal communication, 2006. McGrew MC, Skipper B, Palley T, Kaufman A. Student and faculty perceptions of problem-based learning on a family medicine clerkship. Fam Med 1999;31:171–176. McParland M, Noble LM, Livingston G. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Med Educ 2004;38(8):859–867. Nalesnik SW, Heaton JO, Olsen CH, Haffner WH, Zahn CM. Incorporating problem-based learning into an obstetrics/gynecology clerkship impact on student satisfaction and grades. Am J Obstet Gynecol 2004;190:1375–1381. Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of the evidence. Acad Med 1992;67:557–565. Peters AS, Greenberger-Rosovsky R, Crowder C, Block SD, Moore GT. Long-term outcomes of the New Pathway Program at Harvard Medical School: A randomized controlled trial. Acad Med 2000;75(5):470–479. Washington ET, Tysinger JW, Snell LM, Palmer LR. Implementing problem-based learning in a family medicine clerkship. Fam Med 1999;31:306–307. Zisook S, Benjamin S, Balon R, Glick I, Louie A, Moutier C, Moyer T, Santos C, Servis M. Alternate methods of teaching psychopharmacology. Acad Psychiatry 2005;29(2):141–154. Review.

Part II

Human Behavior

Chapter 2

Childhood Development Maya Strange and Andrea Sorensen

In order to detect and diagnose pathology in children and adolescents, clinicians need to recognize the bounds of normal behaviors. Rapid changes in the developing child make “normal” behavior a moving target. These three cases illustrate some of the challenges to parents and professionals. At the end of this chapter, the reader will be able to 1. Describe normal emotional development in a preschool age child, a middleschool age child and an adolescent. 2. Discuss protective factors for normal development and how parents can foster normal development in a child. 3. Identify ways in which stages of development, personality traits, family, culture and society influence adaptation and coping. 4. Describe some risk factors for developing psychopathology at various stages of development. 5. Relate how a child’s developmental stage influences the physician–patient interview.

Case Vignette 2.1.1 Presenting Situation: Caleb You are a third-year resident at a pediatric clinic where 34-month-old Caleb is brought in by his parents with the concern that he has emotional outbursts. With further discussion, Caleb’s mother shares that she has a sister diagnosed with Bipolar Disorder and is concerned that he has a mood disorder or Attention-Deficit Hyperactivity Disorder “like his cousins.” The parents describe that Caleb can “rage.” They say that he lies on the floor and flails around while screaming or runs from them and slams doors. He sometimes stands with stiff arms and legs and cries inconsolably.

M. Strange Assistant Professor of Psychiatry, University of Nevada School of Medicine

A. Guerrero, M. Piasecki (eds.), Problem-Based Behavioral Science and Psychiatry, C Springer Science+Business Media, LLC 2008

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M. Strange, A. Sorensen


Case Vignette 2.1.2 Continuation The parents note that the “rages” can last up to 10 minutes and may occur several times a day. They both agree that triggers for the outbursts may be when he doesn’t get what he wants, when they may not understand him, and when it is around nap or bed time. The father says that he is able to speak sternly with Caleb or sit him in a chair for 1–2 minutes, after which he usually calms down. The mother says that she can become frustrated with him and usually ends up yelling at him to be quiet. When you ask, she gives an example from that morning: she gave Caleb crayons and paper but he only colored for a few minutes and then wanted to play with blocks. She redirected him to the coloring and he sat on the floor and “raged” for 5 minutes. She yelled “Stop it!” then felt guilty, so she gave him the blocks and walked away. Caleb was the product of a full-term first pregnancy without exposures or complications. He was easy to feed and has always slept well at night. He responded appropriately socially, with babbling and peek-a-boo play in infancy, pointing at objects as a toddler, and enjoying being with other children as a toddler. He crawled at 10 months and walked at 15 months. Currently, he can eat with a fork, undress, ride a tricycle, color a circle and a line, and identify colors and much of the alphabet. He speaks in three-word sentences and demonstrates a quickly growing vocabulary. He has no significant medical illnesses or significant injuries. They tell you that Caleb seems happy outside of these episodes. You ask to see Caleb alone, and he agrees to let his parents leave the room. On exam, Caleb seems shy, but then starts to push a toy truck around the room while he makes truck sounds. He colors on a sheet of paper and hands you a pen and asks you to draw a circle. He then draws several circles as well and smiles. He is able to build a nine-block tower, then knocks it over and laughs. He finds a Spider Man toy, and you respond “You found Spider Man.” Caleb then starts to tell you how the superhero jumps and gets the bad guy. He jumps up and down himself. He tells you that he has a Spider Man at home that he sleeps with in his bed. He asks for his mother a few times during the exam, but is willing to keep playing. He makes good eye contact and shares smiles. He denies that anyone has ever hurt him or made him particularly scared (he does admit he’s scared of the dark). When his parents return, he runs to his mother and hugs her.


2 Childhood Development

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Case Vignette 2.1.3 Continuation Caleb attends daycare 3 days a week for the past 6 months. The teacher told Caleb’s mother that he did have difficulty sharing with the other kids initially. He would tantrum, sometimes to the point of hitting other children, if he had to share toys. He responded to counts to three and time-outs in the time-out chair at school. The teacher counts to three to give him time to calm down or facilitates a trading of toys when another child has what he wants. He can also choose to play with a different toy. If he does not make a trade, play with a different toy, or calm down by the count of three, then he gets a time-out. Initially he required several time-outs a day, but for the past 2 months has had only one time-out every few days. The teachers have not noted any other concerns.

Learning Issues Caleb behaves like a normal boy of his age. His cognitive development is on track: he is using multiple word sentences and pronouns, he names objects, colors, and knows letters. His daily living skills are also well developed for his age. Nearly 3 years old, he is learning to use utensils, undress, and even dress himself and use the toilet. His motor skills are also on target, as he is able to effectively interact with and explore his environment. Socially, he demonstrates that he is able to communicate, appreciate personal boundaries, and share affect (Smidt, 2006). His play and conversations remain self-centered, but this is expected in toddlers and preschoolers. This self-centered perspective of the young child can be frustrating for many adults especially if they do not appreciate this developmental stage. Caleb is only focused on his interests and does not ask the examiner of her opinion or her interests. His attention span is limited to 5 or 10 minutes, and he changes activities frequently. It is clear, however, that the examiner’s presence is important to Caleb. The adult provides a reference for the child and can serve to share experiences and encourage appropriate exploration, communication, and expansion on Caleb’s own self-awareness during his play. According to Erikson, a child of this age is in the midst of the developmental phase of autonomy versus shame and doubt (18 months–3.5 years), during which the child seeks to attain autonomy. As the young child becomes more aware of being a separate individual with differing wants/needs from the parents, he or she may start to strongly resist limits. “No!” is a common refrain heard by parents. There is a battle of the wills as the child attempts to exert initial control. Effective communication and established trust between the child and the caretaker are essential for how this stage is resolved. In fact, parents who learn to apply supportive interactions will have ongoing rewards, as the child’s efforts toward greater separation may begin during this phase but will continue throughout childhood (Wiener and Dulcan, 2004). It is also important to consider the neurodevelopment occurring in the preschooler’s brain. At birth, the human brain already has a hundred billion neurons, but is still only a fraction of the size it will be in adulthood. As a child experiences

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life, these neurons branch dendrites and synapse to one another to form networks of great complexity that integrate their understanding of their environment and their control over their own abilities. The brain also develops by layering neurons with insulating myelin to increase the speed of conducted information. Finally, this process is completed by the neurons pruning themselves of less useful dendritic and synaptic connections (Higgins and George, 2007). Only one-fifth of neurons are programmed by the age of 2. Through exploration and testing of limits, the young child gathers data for programming the other 80 % of the brain. The child’s desire for social and environmental interactions are paramount to learning (Lewis, 2002). Most parents understand that they serve a critical role in providing a safe and interesting environment as well as rules and structure to help children learn without physical injury. Emotional development and learning affective (emotional) regulation also requires such interactive parenting. A child may push the limits of behavior in an attempt to further engage in exploration and continue his self-serving behaviors. A caregiver can acknowledge this desire and voice an understanding that the child desires to learn. (“I know that you want to go across the street and see how the garbage truck picks up garbage.”) It is important to remain accessible to the child to help shape his or her expectations. The caregiver can clearly identify the child’s desires versus the real and acceptable options for the child. (“We can’t go near the truck, but we can watch it from over here or go home and read about trucks.”) Offering the child options and time to make a decision helps the child develop self-awareness and problem solving. When children resist and retaliate, it may be time for a brief and respectful consequence. If the child makes a good choice then it is helpful to immediately praise the child. Consistency in these ongoing interactions models appropriate emotional and behavioral regulation and also nurtures the child’s security and attachment with the caregiver. Piaget noted that the 2- to 5year-old child is in a preoperational developmental phase, which is egocentric from a cognitive, affective, perceptual, and social standpoint. Sociocultural theorists describe, however, that children this age utilize significant social referencing. They offer the concept of scaffolding, in which problem solving for the young child occurs with helpful adults who are the child’s primary tool for learning (Lewis, 2002).

Case Vignette 2.1.4 Conclusion You reassure Caleb’s parents that he is normal, bright and healthy. You offer your favorite resource for parenting: 1,2,3 Magic! (Phelan, 2003) and Your Child (Pruitt, 2000), as well as the American Academy of Child and Adolescent Psychiatry’s website, with resources for parents. You strongly recommend that both parents observe the preschool teacher’s techniques so that they can see what works at the school and be consistent at home. A local resource for parenting classes is reviewed. They are encouraged to return to the clinic if these initial recommendations are not effective for the family.


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Case Vignette 2.2.1 Presenting Situation: Susana Susana is a 10-year-old Hispanic girl brought to your Outpatient Clinic by her mother, who is worried that she has had difficulty concentrating and crying episodes in the past few weeks. The girl sits politely next to her mother with a sad expression and wide opened eyes. She is holding a rubber toy dinosaur close to her chest with her right hand and is touching her mother’s arm with her left hand. Susana is an only child and has not had any major health problems in the past.


Case Vignette 2.2.2 Continued Susana’s mother tearfully tells you that her husband, Susana’s father, passed away from cancer last month. He had been sick for several months and in hospice care at their home. She says that even before he died, Susana had been having difficulty completing her work at school and her homework. Susana’s teacher sent a note home that her worksheets are covered with drawings of clouds and the sky. Her mother tells you that Susana has been crying for about 20 minutes a few times a day for the past several weeks. One time she became frantic when she couldn’t find the toy dinosaur that she has been carrying with her for the past 2 months—a gift from her father for her ninth birthday. She also has awakened her mother at night in a panic needing to find a particular T-shirt that her father used to wear. Once she finds the shirt, she goes back to sleep. Her mother notes that even though her sleep has been disturbed, her appetite has remained fine. You glance at the chart and see that Susana is slightly above the 50th percentile for weight.


Case Vignette 2.2.3 Continued When asked about their support system, Susana’s mother tells you that they do not have much family, but they do attend a grief group at their church. They have been able to talk about the impact of the father’s death.

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You ask to speak to Susana alone. When asked about friends, Susana tells you about two close friends. She has been able to play with them and tells them her feelings about missing her father. Susana tells you that her grades continue to be good in school, and she enjoys riding bikes or playing computer games. She feels angry when she sees other kids with their fathers. She still feels that it is unfair that her father had to die. Looking at the sky and the clouds are a comfort because she feels her father is “up there” and with her always.


Learning Issues Grief is the emotional pain or anguish that one feels after the loss of a loved one. Anticipatory grief is a similar emotional pain that occurs before the impending death. Three categories, based on age and maturity, of a child’s understanding of death have been described. Three to five-year-old children look at death as sleep or a long journey. Five to nine-year-olds accept that someone can die; however, they do not believe it happens to everyone and especially not to themselves. By 10 years of age, children know that death is inevitable and that it may happen to them. Normal bereavement is not considered a disorder, and loss of a close friend or relative occurs to up to half of all youths by the age of 21. Loss of a parent may occur to approximately 4 % of children by age 18 (Lewis, 2002). Susana’s developmental phase has been described by Erikson as industry versus inferiority (5–12 years old). This is a time during which a child develops a sense of competence and focuses on self-worth. The child learns how to become a friend and to identify with a peer group. He or she also gains satisfaction in experiencing hard work that leads to success and also learns to compensate for their weaknesses in some areas by noting accomplishments in other areas. The child not only learns to read but eventually “reads to learn.” Motor development also progresses, and physical activity can be a positive way to engage with peers and master a talent (e.g., playground games such as tag; team sports such as soccer and softball). Piaget describes the cognitive stage of concrete operations. The child is able to conceptualize rather than simply perceive, but is not yet able to utilize abstract thinking. Thus, Susana may understand the irreversibility and inevitability of death, but may have difficulty in applying the concept generally. She may continue to have concerns about potential harm to her own body, not just her father’s. Mastery of these thoughts may be seen in dreams or play. If the child becomes overwhelmed, however, he or she may feel vulnerable or even helpless.


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Just as a child’s body goes through a maturation process at puberty, her brain also undergoes regular maturation processes through the formative years. Susana is at an age where she is just between two peaks in brain development. Between the ages of 4 and 8, her brain continues the process of development. This occurs through gray-matter loss and by maturing the primary sensorimotor regions which consolidate basic sensory and motor function. Between the ages of 11 and 13 her brain will peak in development in the regions of spatial orientation and language (Toga et al., 2006). This process of gray-matter loss maturation will go on through adolescence. From the earliest studies on brain volumes, children between 8 and 10 have been shown to have significantly more cortical gray-matter relative to cerebral size than young adults do (Sowell et al., 2004). Thinning of specific regions in the brain represents focused maturation of the cognitive abilities associated with those regions. For example, thinning of the left dorsal frontal and parietal lobes in children aged 5–11 has been correlated with improved performance on a test of verbal functioning (Toga et al., 2006). Further research is needed to clarify the psychiatric morbidity among adults who lost a parent in childhood. It helps to recognize complicated bereavement in children in order to minimize morbidity later in life for these individuals. Symptoms of complicated grief are: longing and searching for the loved one, preoccupation with thoughts of the loved one, purposelessness and futility about the future, numbness and detachment from others, difficulty accepting death, lost sense of control and security, and anger and bitterness over the death. The anger can lead to problems in interactions with family and friends, schoolwork, and other activities. Even 2 years after the parent’s death, preadolescent girls were noted to have more anxiety, depression, and aggressive behaviors than controls, and adolescent boys were noted to be more withdrawn and have more social problems than their matched controls. Adolescent girls and preadolescent boys showed no differences from their matched controls. Overall, approximately 20 % of children who suffered the death of a parent had serious problems at 1 year that could require treatment such as counseling (Melham et al., 2007).

Case Vignette 2.2.4 Conclusion You are able to reassure Susana’s mother that she is experiencing normal grief. This can present in myriad ways—some children cry, some avoid, and others respond by denying that the death occurred. Susana and her mother were commended for their open communication and participation with community and peer groups that are supportive. It will be important to maintain open lines of communication to allow Susana to express sadness, anger, and memories of her father as she works to process grief. You advise Susana’s mother to be aware of signs of pathological grief, as described above. Many cities have bereavement groups and resources for children who have lost a parent. This can be a wonderful source of support, because often a child can otherwise feel very alone in this experience.

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Case Vignette 2.3.1 Brian Brian is a 15-year-old male with a history of insulin-dependent diabetes who comes to your family medicine clinic with his mother. He is currently in the 10th grade at the local public high school and lives with his mother, 17-year-old-sister, and 11-year-old brother. Brian’s parents divorced when he was 9. His father, who lives in town, sees Brian and his siblings every week. His mother brought him to see you for an evaluation due to concerns about some of his recent behavior. Over the past 6 months, he has changed from a “sweet, loving, and attentive son,” to a “stranger.” She tells you that he spends most of his time in his room, on the phone with friends, or on the computer. He used to be a conscientious student, but recently has been doing his homework at the last minute. The last semester he lost his 4.0-grade average and currently has three Bs on his report card. Brian has also been staying up late and sleeping in more on the weekends. His taste in music and dress has changed. She describes that he used to be very neat, but more recently has been wearing “skater” clothes, and he pierced his ear and eyebrow. He has been talking about getting tattoos. His eating habits have changed, and he has been more casual about managing his blood glucose levels.


Case Vignette 2.3.2 Continuation You meet with Brian without his mother. He is soft-spoken and cooperative, with brown shaggy hair, a large hooded sweatshirt and baggy jeans. He tells you he doesn’t know why his mother brought him in and that she “overreacts” to everything. Brian reports that he was diagnosed with diabetes when he was 10 years old, “so things were pretty stressful then.” He says, “I know I should do better (managing his diabetes), but sometimes I just want to eat without thinking about it, and it’s a pain carrying my insulin around all of the time.” Brian used to spend more time at home in elementary and middle school because “I didn’t have anyone my age to hang out with, so I hung out with my mom.” He states that his mother is fairly strict. “It’s unfair. My sister would never do anything my mom wouldn’t like, so she now doesn’t know what to do with me.” He doesn’t tell his mother too much about his girlfriend or his friends “because it usually turns into a lecture.” Brian also has positive things to say about his family: “My mom is an awesome cook, and she would do anything for us. My sister is kind of a dork, but she always looks out for me.” Brian tells you that school has been going fairly well, though he could try harder. He skipped school a few times when the weather was warmer to go skateboarding with friends. He also has a girlfriend and says it’s a serious relationship. He had


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few friends when he was younger and, until a couple of years ago, he was one of the shortest children in his class. Since starting high school, he has grown 11 inches and is now 5 9 tall. In high school he has established a large group of friends. When you ask him about substance use, he tells you that he has tried alcohol and marijuana at parties, but “they’re not for me.” He denies discipline problems in school, with the exception of getting detention in middle school for once having a water balloon fight during recess. He denies any history of stealing, fire setting, harm to animals, or running away. He has never been in trouble with the law. He notes that his mood overall the past several months has been good. He has been sleeping well, but does stay up until 12 a.m. because he is either online or talking on the phone. When his parents divorced, he remembers that he was easily frustrated and somewhat angry at his father, but he continued to enjoy his usual activities and perform well in school. He has a good appetite and denies history of or current suicidal ideation or self-injury. In addition to skateboarding, he likes to write, listen to music, and play guitar. He works at an ice cream shop 10 hours per week, and reportedly his supervisor hopes he can work longer hours during his school breaks. Brian’s ultimate goal is to become a professional skateboarder, but if that does not work out, he would like to eventually open his own skate shop or do “accounting, like my dad.” You invite Brian’s mother to talk with you alone. Brian was diagnosed with diabetes after presenting to the emergency room in diabetic ketoacidosis. Brian’s mother strictly managed his diet and blood glucose levels. Recently, Brian has wanted more responsibility, and his last hemoglobin A1C was 7 (previous levels had been in the normal range). She tells you that Brian is a “great kid,” but points out that her own brother had some behavioral difficulties when younger, and started using substances during high school. Brian’s mother was raised in a very religious household, and her brother was regularly in conflict with the family. Her brother continues to use substances, has irregular contact with the family, has spent time in jail related to his drug use, and has been unable to maintain steady employment. Brian’s mother says, “I may be completely off base, but I just don’t want to see what happened to my brother happen to Brian.”


At this point the differential remains quite broad. Brian’s change in behavior including being more isolative, change in school performance and sleep patterns could suggest possible substance use, depression, or even disruptive behavior disorder. It would be important to understand how Brian’s change in behavior is affecting his function in other areas, such as with friends, school, or work. Teenagers at risk for developing serious substance problems include those who: have a family history of substance use, are depressed, have low self-esteem, feel like

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they do not fit in or are out of the mainstream. Signs and symptoms of substance use may be physical fatigue, repeated health complaints, red or glazed eyes, and a lasting cough. Emotional complaints may be personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and general lack of interest. The family may notice the teen argues more, breaks rules, and is more withdrawn. School concerns are decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems. The teen may have new friends who are less interested in standard home and school activities, have problems with the law, and are interested in less conventional styles of dress and music. It is important to discuss substance issues as well as screen for mental health disorders, as 10–15 % of the child and adolescent population have symptoms of depression at any one time (Smucker et al., 1986). The prevalence of major depression among children aged 9–17 has been estimated at 5 % (Shaffer et al., 1996) and substance use disorders are quite common. Another consideration would be a normal variant of adolescent development. According to Erikson’s stages of development, adolescence (12–17 years) is the period of identity versus identity diffusion. The adolescent’s goal is the answer to the question “Who am I?” As the adolescent tries to figure this out, they may experiment with different identities and rebel against some adult expectations. This stage accompanies significant physical changes and further development of gender identity. The teen’s social network increases in importance. The adolescent engages in various activities as he or she determines his or her own values and goals. The developmental goals during this time include not only solidifying one’s own identity, but also separating and reconciling one’s feelings for the family of origin, developing romantic relationships, and mastering one’s bodily functions and impulses (Wiener and Dulcan, 2004). The normal process of separation and individuation can make this a challenging time for parents. As adolescents approach adulthood their brains continue to develop in areas of greater and greater complexity. For example, the process of myelination to insulate neurons into greater conduction speed is already finished with ventral and deep brain structures that control primitive functions, but continues on in dorsal regions responsible for higher cognitive functions, like the prefrontal cortex, onward to adulthood. In the peak adolescence years after puberty the brain matures specific regions devoted to integrating senses and reasoning (“executive function”) (Blakemore and Choudhury, 2006) (Toga et al., 2006). This picture of brain development matches with Erikson’s stages of development, as it represents the brain developing in areas associated with response inhibition, emotional regulation, planning, and organization or, in other words, self-control and personal choices (Sowell et al., 2004).

Case Vignette 2.3.3 Conclusion You discuss with Brian’s mother that Brian (and she) are likely experiencing normal adolescent development. Though Brian may at times seemingly push his family away, he needs her to remain present and consistent while allowing him to explore


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as much as is safe (similar to in toddlerhood). It will be important to continue to express the family’s values and expectations to him, though in a non-shaming way. Continuing to engage in activities as a family is also helpful to maintain open lines of communication. You refer Brian’s mother to the AACAP website, particularly to the Normal Adolescent Development sections. You also meet a few months later with Brian and his mother together to discuss how each feels things are going in the family. You allow time for clarification of certain rules that are non-negotiable. It is helpful for Brian’s mother to hear from him his perspective and overall positive feelings about the family.

Review Questions 1. What process of neurodevelopment is responsible for the great speed information travels in the brain? (a) (b) (c) (d)

Loss of unnecessary gray-matter. Myelin insulation of neurons. Pruning excess dendrite and synapse connections. Forming new dendrite and synapse connections.

2. Which of these statements about a 3 year old would be developmentally unusual? (a) (b) (c) (d)

The child eats with a fork or spoon. The child focuses conversations on an adult. The child can ride a tricycle. The child’s attention span only lasts 5–10 minutes.

3. What would be a sign that a child’s grief at the loss of a parent had become complicated bereavement? (a) (b) (c) (d)

Numbness and detachment from others. Seeking out objects belonging to the deceased. Bouts of crying between normal behavior. Preoccupation with activities associated with the decreased.

4. What brain morphology change is correlated to improved verbal function test scores? (a) (b) (c) (d)

Thickening of the right dorsal frontal and parietal lobes. Thinning of the right dorsal frontal and parietal lobes. Thickening of the left dorsal frontal and parietal lobes. Thinning of the left dorsal frontal and parietal lobes.

5. Which of these is associated with 15 year olds according to Erikson? (a) (b) (c) (d)

Satisfaction in hard work that leads to success. Resisting limits to develop autonomy. Learning to identify with a peer group. Determining personal goals and values.

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6. What percentage of the child and adolescent population has symptoms of depression at any one time? (a) (b) (c) (d)

1–5 % 5–10 % 10–15 % 15–20 %

Answers 1. b, 2. b, 3. a, 4. d, 5. d, 6. c

References Blakemore, S. and Choudhury, S. (2006). Development of the adolescent brain: implications for executive function and social cognition. J Child Psychol Psychiatry 47(3/4), 296–212. Higgins, E.S. and George, M.S. (2007). The Neuroscience of Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins. Lewis, M. (2002). Child and Adolescent Psychiatry: A Comprehensive Textbook. Philadelphia: Lippincott Williams & Wilkins. Melham, N.M., Moritz, G., and Walker, M. (2007). Phenomenology and correlates of complicated grief in children and adolescents. JAACP 46(4), 493–499. Phelan, T. (2003). 1-2-3 Magic: Effective Discipline for Children 2–12. Glen Ellyn: Child Management, Inc. Pruitt, D. (2000). Your Child: Emotional, Behavioral, and Cognitive Development from Birth through Preadolescence. New york: Harper Collins. Shaffer, D. et al. (1996). The NIMH Diagnastic Interview Schedule for children, version 2.3 (DISC 2.3): Description, acceptability, prevalence rates, and performance in the MECA study methods for the Epidemiology of child and Adolescent Mental Disorders Study. J Am Acad Child Psychiatry 25, 865–877. Smidt, W. (2006). Nelson Essentials of Pediatrics. Philadelphia: Elsevier Saunders. Smucker, E.R., Craighead, W.E., and Green, B.J. (1986). Normative and reliability data for the Children’s Depression Inventory. J of Abnormal Child Psychology 10, 277–284. Sowell, E.R, Thompson, P.M., and Toga, A.W. (2004). Mapping changes in the human cortex throughout the span of life. Neuroscientist 10(4), 372–392. Review. Toga, A.W., Thompson, P.M., and Sowell, E.R (2006). Mapping brain maturation. Trends Neurosci 29(3), 148–159. Review. Wiener, J. and Dulcan, M. (2004). The American Psychiatric Publishing Textbook of Child and Adolescent Psychiatry. Arlington, VA: American Psychiatric Publishing.

Resources www.aacap.org Normal Adolescent Development Part I, No. 57; updated June 2001. www. aacap.org/cs/root/facts for families/normal adolescent development part i.


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Normal Adolescent Development Part II, No. 58; updated June 2001. www. aacap.org/cs/root/facts for families/normal adolescent development part ii. Normality, No. 22; updated July 2004. www.aacap.org/cs/root/facts for families/normality. When to Seek Help For Your Child, No. 24; updated July 2004. www.aacap.org/ page.ww?section=Facts+for+Families&name=When+To+Seek+Help+ For+Your+Child. www.aap.org Refer to Caring for your Child parenting books. www.brightfutures.aap.org Clark, L. (2005). SOS Help for Parents Bowling Green: SOS Programs and Parents Press.

Chapter 3

Effects of Experience on Brain Development Jeffrey Raskin, Whitney Waldroup, Nikhil Majumdar, and Melissa Piasecki

The classic “nature–nurture” debate continues to stimulate research in human behavior. This chapter explores how experience (nurture) can modulate brain architecture and brain function. These cases illustrate how childhood experiences can have lifelong effects on behavior and well-being. At the end of this chapter, the reader will be able to 1. 2. 3. 4.

Discuss the role of early experience on normal brain development Identify early adverse effects of deprivation Determine some common deficits which result from early deprivation Describe resilience and differences in innate ability

Case Vignette 3.1.1 Peter Magellan As the Chief Resident in a pediatrics outpatient office, you pause outside a patient’s room to read the chart. You learn that inside the room there is a concerned couple and their adopted son. Having been unable to conceive naturally, the Magellans adopted a foreign-born child, Peter. They were assured at the time of adoption that Peter was 2 years old and had a normal gestation. He was born at term and is without congenital defect. Mr. and Mrs. Magellan have been waiting quietly in the exam room with their newly adopted son. Good morning Mr. and Mrs. Magellan. My name is Dr. Sam and I will be working with you today. What brings you in? You notice Mr. Magellan remains quiet as his wife begins nervously. Mrs. Magellan: Well, Doctor, we’re very concerned because we adopted Peter four weeks ago and it seems that he just doesn’t act like the other kids his age at the playground. We thought that maybe he was closed off just because ofthe change

J. Raskin Medical Student, University of Nevada School of Medicine


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in location and language, and that it would probably pass, but . . . I don’t know now. The social worker told us there may be some differences, but we just didn’t anticipate this. He looks really small and he weighs less than the other kids too. Is this normal? You notice that Peter has been quiet and still, sitting stiffly in a chair by himself, clutching a dirty looking teddy bear. He does not appear to have any interaction with his new parents. His eyes do not meet yours even when you approach him at his level. He appears frail and withdrawn. You see on the chart that Peter weighs 22 pounds and is 31 inches tall. Mrs. Magellan: What’s wrong with him? You tell the parents that although Peter falls below the fifth percentile on the CDC growth chart for boys, this is not by itself a sign of a medical problem. You obtain more information on Peter’s development. He uses one-syllable words and gestures to communicate. Although he uses the toilet, he cannot manage his clothing. He also is unable to climb down the stairs and must be carried. The Magellans bought a quantity of toys for 2-year-olds, but Peter does not show any interest in the puzzles or blocks. Mrs. Magellan describes the adoption: Well, I read about how many orphans there were without proper care in Romania and we decided it would be best to try to save at least one of them. We looked at hundreds of babies and toddlers online and just fell in love with Peter’s little cheeks. The orphanage in Romania seemed like a reputable place. There were so many babies to choose from . . . maybe we should have not gone to Romania or we should have used a different agency. She looks at Peter. Doctor, is there anything we can do that may make Peter more normal?


Case Vignette 3.1.2 Continuation The Denver Developmental Screening Test showed that, for a 2-year-old, Peter has significant areas of deficit including fine motor control, gross motor control, personal social skills, and language skills. Physical exam was negative for any abnor-

3 Effects of Experience on Brain Development

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mal finding, including heart murmur, pallor, capillary refill delay, or respiratory problem. You tell the parents: First we will run some simple tests on his blood and stool to make sure there isn’t an organic cause for his size and behavior. You order the following: a Complete Blood Count (CBC), thyroid function tests (TFTs), a chemistry panel, a screen for lead poisoning, and a screen for tuberculosis. You recommend a multivitamin, offering a variety of foods and a follow-up visit in 2 months. You also recommend that the parents spend lots of time reading and playing with Peter. You encourage “sandbox time” at the playground with other 2-year-olds.


Case Vignette 3.1.3 Continuation You search the Internet for Peter’s adoption agency and learn about the protocol for adoptions. The website indicates that all prospective parents get counseling prior to the adoption and that there is a social worker who follows up as well. The website places emphasis on an orphan’s special needs for “extra tender loving care.” You make a follow-up phone call to the Magellan’s residence, 2 weeks later to let them know about the test results. All of the test results were normal. Mrs. Magellan picks up the phone and tells you, Hi Doctor! Peter smiled the other day and we found some foods he likes. It seems like he is already responding.


Case Vignette 3.1.4 Continuation Three months later, when you pause outside the room to read over Peter’s chart for his follow-up appointment, you hear the unmistakable sound of a child giggling. You enter to see Peter sitting on Mrs. Magellan’s lap and Mr. Magellan tickling his feet. You greet the parents. It looks like Peter is having some fun there. Sitting down on a low stool you look into Peter’s eyes. How are you today Peter? Peter turns away, squirming back into his mother.

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Mrs. Magellan: Oh, Hi Doctor. As you can see Peter is quite a bit more social with us. When we talked a couple of weeks ago it seemed that Peter was just coming out of his shell, but now he really does great. He’ll point at things he wants and he seems to have a healthy appetite, though I don’t know how much weight he has gained. He still doesn’t use many words though, and sometimes he throws temper tantrums. Dr. Sam: Well, the progress he has made already is phenomenal. You two really are great parents. According to his chart, he weighs 24 pounds and is 31 inches tall. He’s gained two pounds and grown a half inch. Mrs. Magellan: Did we do something wrong? I thought he was interacting so much better with us now—shouldn’t he be up higher on the growth chart? Dr. Sam: Well, typically a child will stay on one of the percentile lines once they begin being traced on it. It is possible that Peter will always be smaller than most boys his age. It is also possible that, given more time, Peter will start to grow more and move up the percentiles. Right now is it not possible to tell. A varied diet and home enrichment will be the best treatment. Later on, it may be helpful for Peter to be enrolled in a speech or language program to help his language acquisition. Let’s see Peter again in a few months to make sure he continues on the right track. You are doing a fantastic job with Peter. Looking at Peter, you tickle his leg. Peter smiles shyly and turns toward his mother.


Case Vignette 3.1.5 Conclusion Two and a half years have passed since you last saw the Magellan’s, and you have been very busy in your new practice. Somehow, you missed the Magellan’s as you transitioned from Chief Resident to Attending. Today you look at the chart with amazement. Walking into the room, Mr. and Mrs. Magellan sit talking quietly while 5-year-old Peter creates a car out of connecting blocks. Mr. Magellan tells you that Peter started a toddler program 2 years ago and then preschool last year. Peter’s language and motor skills are up to speed with his preschool peers. You look twice at the growth chart: Peter is at the 25th percentile. Peter looks through his glasses at you, Hello Doctor. Grinning, he returns to his blocks. Mrs. Magellan is beaming as she tells you “Peter knows his ABC’s and can even count to twenty. He’s ready for kindergarten next fall.”


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Learning Issues Early Deprivation from Institutionalization Although there is a degree of variability in standards of care within orphanages internationally, many are overburdened with children. With high staff to child ratios and inadequate resources, some children do not receive adequate nutrition, stimulation, personal contact, or education. These types of conditions lead more than half of orphans adopted from Eastern Europe to lie below the fifth percentile in length/height and weight scales (Judge, 2003). This statistic is exclusive of those children with yet undiagnosed medical conditions. After 6 months in enriched adoptive environments, the majority of adopted children significantly outgrow developmental and growth delays. The longer the stay in the orphanages, the more diverse and severe the deficits experienced by the child.

The Importance of Early Attachment Infants of many species require a nurturing bond with an older member of the same species. Most often this bond is formed between infant and mother. The anecdotal baby duck hatchling forming an unchangeable nurturant bond with the local pig is well known and does occur due to imprinting. Attachment is another term for the bond between mother and child. Evidence of good attachment is attunement, where the mother and child respond to each other’s cues. A well-attached child will be soothed by the mother after an upset and over time will learn to self-soothe. Healthy attachment allows for healthy development of the infant’s motor and social skills as well as overall growth. Perhaps the most famous research investigating the importance of bond formation was by Harry Harlow and his rhesus monkeys. Dr. Harlow was an American psychiatrist interested in defining the importance of early bond formation. Although his research is considered unethical and would never be performed in today’s laboratories, he found that isolation of baby macaque monkeys from other monkeys for up to 24 months led to severe social disturbance. When a substitute mother monkey covered in either cloth-like material or wire was offered, the monkeys chose the cloth-like material surrogate over the wire surrogate. Baby monkeys only chose the wire surrogate if it offered food and the cloth-like mother did not. These early experiments provided a base for understanding the intricacies of early bond formation (Harlow et al., 1965). Disrupted or unhealthy attachment can lead to problems in childhood and beyond. Such is the case in situations like orphanages, children in serial foster homes, or children in neglectful and abusive homes. Post-partum depression can also severely affect mother–child bond, consequently possibly leading to psychological disturbance in childhood and beyond (Miller et al., 2002). Anaclitic depression is

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a disorder in children separated from their caregiver and who then fail to thrive (grow and develop). Children with prolonged separation from a caregiver will experience deficits in one or more categories defined by the Denver Developmental Screening Test, such as fine motor control, gross motor control, personal social skills, and language skills. Children may also develop problems with trust that can affect social relationships later in life. Deprivation longer than 6 months worsens symptoms and can lead to long-term difficulties in social functioning.

Disruption of Early Attachment Affects Neural Circuitry Successful formation of the caregiver (mother)–infant bond provides the basis for normal brain development. The potential difficulties that arise from abnormal brain development are problems such as depression, inability to self-soothe, and instability in relationships. Research has identified the right brain as the site of early emotional development. Research suggests that healthy attachment promotes development of emotional regulation centers in the right side of the brain during infancy and deficits in attachment (as well as abuse and neglect) disrupt the normal organization in the right brain during the first 3 years of life. Schore has documented EEG findings as evidence of changes in right brain development. Maternal environmental conditions play a role in the brain development of the offspring. Animal studies reveal how stress during pregnancy or maternal separation can increase the seizure risk in the offspring or evoke psychological symptoms in the offspring consistent with anxiety and mood disorders. Compared to rats with non-stressed mothers, the offspring of the stressed mothers later had significantly increased the output of the hypothalamic–pituitary–adrenal axis (see Chap. 11) (Edwards, 2002). People who suffer early trauma are at risk for other problems as well. Depression and anxiety occur at higher rates for people with early trauma histories (Heim and Nemeroff, 2001). Animal studies show that babies that are stressed by separation from their mothers later have problems with socialization and anxiety and are more likely to self-administer substances (Huot, 2001).

Resilience as a Basis for Different Child Response Rates The formation of attachment between mother and child is subject to complicated interactions between nature and nurture. There is an innate temperament among babies that contributes to the formation of a successful bond. This innate difference between babies may underlie the property of resilience. Resilience allows an individual to grow and develop, despite significant setbacks or disadvantages. The term resilience defines an ability to maintain, to prevail, and, in some cases, to thrive in the face of problems such as child neglect or mistreatment, exposure to violence, or mental illness in the home. Children who exhibit resilience


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Table 3.1 Personality traits correlated with resilience Intelligence Mutability Charisma Easy going Perseverance

High intelligence is correlated with increasing abilities of children to succeed despite stress The extent to which personality can be molded in the long-term seems highly correlated with resilience An undefined trait in which some individual phenotypes are more socially acceptable Like the concept of mutability, but less rigidity in the everyday routine As a more mature trait it really is a manifestation of resilience, but when present as a child it seems to be a harbinger of resilient ability

are more often described as charismatic, intelligent, easy going, or socially adept (Luthar, 2005). Resilience can be strengthened during child development by the presence of at least one strong relationship with a meaningful caregiver. Table 3.1 summarizes personality traits correlated with resilience.

Full Circle: Neuronal Circuitry Affects Global Development As discussed, resilience is an adaptive behavior of an individual, and like all behaviors, it relates to a neural substrate. Many researchers are attempting to correlate biological functions with the development of resilience. Stress is correlated with biological responses, i.e., fear and increased heart rate, based on the physiological hypothalamic–pituitary–adrenal axis. Resilient children may have a lower biological response to the same stressors as cohorts. Extreme levels of stress may result in psychogenic dwarfism—a condition where psychological stress during childhood interferes with growth to the point of dwarfism despite adequate nutrition. Very high levels of cortisol are implicated as the neurohumoral mechanism underlying these severe growth deficits.

Covering Your Bases: Screening for Non-experiential Causes As seen in this case, a variety of medical tests are used to differentiate medical, and possibly treatable, causes for delayed development. While a complete discussion of delayed development is likely beyond the scope of this textbook and more appropriately discussed in pediatric textbooks, it is important to note that knowledge of the etiology may give a better understanding of prognosis and help guide focused behavioral therapies to treat likely neurocognitive deficits (e.g., in the case of genetic or congenital conditions) or lead to specific preventive or curative treatments (e.g., in the case of malnutrition or heavy metal poisoning) (Table 3.2).

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Table 3.2 Sources of delayed development Classification

Condition

Effect on cognition

Perinatal Infectious disease

Anoxia, hypoxia TORCH Toxoplasmosis Other: hepatitis B, syphilis, herpes zoster Rubella Cytomegalovirus Herpes simplex, HIV

Environmental contaminants

Mental retardation

Nutritional deficiency

Iron deficiency anemia B12 deficiency

Lower cognitive performance Hearing impairment, including deafness Mental retardation or other learning, behavioral, or emotional problems Microcephaly, or small head and brain size Low birthweight or poor growth inside the womb Blindness or other vision problems, such as cataracts Mercury poisoning causes encephalopathy leading to permanent brain damage Lead poisoning is especially important to catch in young children because they absorb more lead than adults after ingestion. Lead poisoning is associated with a vast symptomology, but most seriously it causes permanent damage to the brain resulting in seizures, coma, and death Increased fatigue with anemia. Look for microcytic hypochromic anemia on peripheral smear, hx of heavy menses in teenage girl Neurological symptoms with B12 deficiency. Watch out for macrocytic anemia as a clue

Case Vignette 3.2.1 Presenting Situation: Jane and Sarah Jones You are a second year resident in pediatrics and you notice the last exam room has two charts on the door. It is an intake evaluation for two new patients, twins Jane and Sarah Jones, aged 15. Looking over the history, you notice that Jane and Sarah were raised in separate households after their parents divorced. Jane grew up with her father in New York, and Sarah lived with her mother in Colorado. They are now both living with their mother in California. The chart indicates that they are both in good health but Jane is having problems in school. You enter the room and see identical twin girls and their mother. Hi, I’m Dr. Smith, it’s great to meet you—all of you. Now, who is Sarah and who is Jane? You two look exactly alike! I bet you can play great tricks on your friends. The girls giggle. Ms. Jones speaks up and points to the girls: This is Sarah and this is Jane. So can you tell me what brings you in today? Ms. Jones: We recently moved to the area and we need a doctor for the girls. Jane has been living with her father since she was born and I just recently got her back 2 months ago. I’ve noticed some differences between the girls which I thought was strange because they are identical. Sarah does extremely well in school, excels in band, and just scored in the 90th percentile on the PSAT. Jane is struggling in


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school and did not-so-well on the PSAT; I am worried that she is having a hard time in her new school. You learn that the girls were born at 38 weeks by C-section and that the pregnancy was normal. Their mother did not smoke or drink. Sarah has always been a very healthy child outside of a broken leg from skiing. Jane and her mother don’t know of any health problems. You turn to Jane: Your mother says you are having a hard time in school. What can you tell me about this? Jane looks down as she speaks: I don’t know. It just seems like Sarah is better at school than me. She is probably smarter than me. Jane’s mother tells you Jane is behind her peers in basic skills such as math and reading and that she has a hard time answering questions in class. Otherwise, her teachers say that she tries hard, interacts well with her peers, and is very kind and polite. What I would like to do today is examine both girls. I know that Jane and Sarah look identical but have they ever been checked to see if they are identical or fraternal? We can do a simple karyotype of their chromosomes as a first step. I would also like to check both the girls’ hearing and vision.


Case Vignette 3.2.2 Continuation At a follow-up visit 2 months later, you learn that Jane is still behind at school even though she works with a tutor four nights a week. The girls’ chromosomes have the same banding pattern, which means that most likely they are identical genetically. Both Jane and Sarah have perfect hearing and vision. You ask about developmental experiences. Ms. Jones: I have always tried to keep Sarah busy. As a single mom, I singed her up for lots of activities while I was working. She has always seemed to love music. I started her in piano lessons when she was 4 years old and she has had 11 years of lessons. She also plays the clarinet and is first chair in the school band. Dr. Smith: Congratulations, Sarah. You must be very excited. Now what about Jane? Jane, what kind of things did you do outside of school when you were growing up? Jane: My dad didn’t have much money so I just went to after-school care at my school every day or watched TV at home. My dad didn’t want to get me an instrument so I didn’t get to play in the band when everyone else started in 4th grade. I like basketball—I am going out for the team next week.

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Dr. Smith: That is excellent. Good luck. What I would like to do now, if you are agreeable, is refer the twins to a research center that specializes in twin studies. It might be that the environment that they grew up in is influencing the differences that you see between your daughters. There is a researcher who specializes in twins and I think he would be interested in adding your girls to a current study.


Case Vignette 3.2.3 Conclusion Dr. Davis is an expert on functional MRI and neuropsychological testing and specializes in twin studies. He is excited about the Jones twins as it is rare to have identical twins separated at birth, raised apart for 15 years, and then reunited. It was documented in the referral note that Sarah seems to have grown up in a more enriched environment and has had considerable musical training while Jane did not have the benefit of these early exposures. Jane and Sarah (with their mother’s permission) agree to undergo neuropsychologic evaluation including standardized intelligence testing. There is a follow-up visit 1 month later. Dr. Davis: Welcome back Jones family! I have some thoughts on why Sarah may have an easier time in school. In the testing that we did, the girls’ overall intelligence is very similar. It seems that Sarah, however, is better at remembering things that she learns verbally. One theory is that the differences between the girls are due to their different experiences as children. There have been some recent studies that show musical training at a young age may positively affect the brain and improve certain areas of functioning including those that relate to verbal learning. Sarah started playing instruments at a very young age and therefore the benefits of training on her brain may be more pronounced than if she had started later on in life. Jane had different experiences as a child and may benefit from learning differently. She and Sarah are both excellent visual learners and this should be emphasized in helping Jane catch up in school. I’ll send a copy of the testing results to your pediatrician.

Learning Issues 1. Experience may modulate brain structure size and function This case serves to illustrate how experience may change brain structure and function. Musical training is an example of a specific, measurable experience that has


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been well studied. Research suggests that training at an early age has a positive effect on verbal memory. Magnetic resonance imaging has shown that specific regions of the brain, such as the left anterior corpus callosum, are larger in musicians than in non-musicians (Schlaug, 1995b). Because verbal memory is mainly a function of the left temporal lobe, and visual memory of the right, adults with music training should have better verbal, but not visual, memory than adults without such training. Adults who received music training before the age of 12 have a better memory for spoken words than those who did not. (Chan et al., 1998). Motor-related regions in the cortex play critical roles in the planning, preparation, execution, and control of bimanual sequential finger movements. Researchers find significant positive correlation between musician status and gray matter volume in motor and somatosensory cortex as well as other brain areas. The gray matter volume is highest in professional musicians, intermediate in amateur musicians, and lowest in non-musicians (Gaser and Schlaug, 2003). From this research, we see the potential for experience to impact both brain structure and function. Converse to the studies on the positive effects of music training, a great amount of research has been delving into the negative effects that early exposure to abuse or neglect has on brain function and structure. Studies have shown that childhood abuse is associated with a multitude of brain changes. These include a smaller hippocampus, corpus callosum, and prefrontal cortex, altered symmetry in some cortical lobes, and a reduction in neurons in the anterior cingulate cortex. There is some controversy over whether differences in brain structure between abused and non-abused children are due to the abuse or a predisposing factor for the abuse. Because no ethical experimentation can be done to study the brain before and after abuse, this research must be compared to animal models of abuse to determine whether the structural and functional differences noted in abuse victims are caused by, or causes of, abuse. Unfortunately, some research shows specific neurological changes dependent on the type of abuse, which may be difficult to develop an animal model for. Examples of this are recent findings that childhood sexual abuse is associated with a smaller primary and secondary visual cortex, while verbal abuse is associated with decreased size of small portions of the temporal gyrus that play a roll in processing language (Teicher et al., 2006). Still, all of these types of research offer insight into possible mechanisms for treatment of specific post-abuse psychiatric and behavioral symptoms. 2. Brain plasticity may have a critical period; ability to shape brain structure and function may be best at a young age There are critical periods for types of learning, such as language learning. These critical periods reflect differences in brain plasticity during development. Our brains have the ability to learn and adapt more readily to some experiences at specific developmental periods—when the over-abundance of synapses are undergoing pruning in response to learning. In this example, early musical training may have impacted the patient’s brain structure and function more than musical training in adolescence or adulthood.

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Human brains are born with great potential to learn in response to the environment—plasticity. Impoverished or traumatic early environments can lead to abnormalities in development of brain structure and function. These abnormalities can have longstanding impact on relationships and risk of psychiatric disorders. Alternatively, enriched environments and exposure to experiences during key developmental periods may allow for optimal brain development. Plasticity of the child’s brain represents the greatest vulnerability and the greatest opportunity of our species.

Review Questions 1. Evidence of good attachment between a mother and child includes (a) (b) (c) (d)

Each wishing the other well Attunement to each other’s cues The child eating everything a mother offers The mother crying when her child cries

2. Deficits in attachment are likely associated with early disruption in organization of what neurological function? (a) (b) (c) (d)

Left brain motor center development Left brain emotional center development Right brain motor center development Right brain emotional center development

3. Which of these is a true statement about people trained in music from a young age? (a) (b) (c) (d)

They have better verbal memory than non-musicians. They have better visual memory than non-musicians. They have better verbal memory than they have visual memory. They have better visual memory than they have verbal memory.

4. An English-speaking American child moving to China and learning to speak Mandarin as fluently as a native is indicative of (a) (b) (c) (d)

Resilience Plasticity Attunement Training

Answers 1. b, 2. d., 3. a, 4. b


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References Chan AS, Ho YC, Cheung MC. Music training improves verbal memory. Nature 1998;396:128. Edwards HE, Dortok D, Tam J, Won D, Burnham WM. Prenatal stress alters seizure thresholds and the development of kindled seizures in infant and adult rats. Horm Behav 2002 December;42(4):437–47. Gaser C, Schlaug, G. Brain structures differ between musicians and non musicians. J Neurosci 2003 October 8;23(27):9240–5. Harlow HF, Dodsworth RO, Harlow MK. Total social isolation in monkeys. Proc Natl Acad Sci USA 1965. Heim C, Nemeroff CB. The role of childhood trauma in the neurobiology of mood and anxiety disorders: preclinical and clinical studies. Biol Psychiatry 2001;49(12);1023–39. Huot RL, Thrivikraman K, Meaney MJ, Plotsky PM. Development of adult ethanol preference and anxiety as a consequence of neonatal maternal separation in Long Evans rats and reversal with antidepressant treatment. Psychopharmacology 2001;158(4):366–73. Judge S. Developmental recovery and deficit in children adopted from Eastern European orphanages. Child Psychiatry Hum Dev 2003 Fall;34(1):49–62. Luthar SS. Resilience at an early age and its impact on child psychosocial development. In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2005: 1–6. Miller WB, Feldman SS, Pasta DJ. The effect of the nurturant bonding system on child security of attachment and dependency. Soc Biol 2002 Fall–Winter;49(3–4):125–59. Schlaug G, Jancke L, Huang Y, Staiger JF, Steinmetz H. Increased corpus callosum size in musicians. Neuropsychologia 1995b;33:1047–55. Sowell E, Thompson P, Leonard C, Welcome S, Kan E, Toga A. Longitudinal mapping of cortical thickness and brain growth in normal children. J Neurosci 2004;24:8223–31. Teicher MH, Tomoda A, Andersen SL. Neurobiological consequences of early stress and childhood maltreatment: are results from human and animal studies comparable? Ann N Y Acad Sci 2006;1071(1):313–23.

Appendix

Table 3.1.1 Populated tables for Case Vignette 3.1.1 Peter Magellan What are the facts?


Peter is in the fifth percentile in height and weight

Organic causes Anaclitic depression

What do you want to know next? HPI:

PMH: He is adopted from Romania FH: There is no evidence that Peter is ill SH:


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Table 3.1.1 (continued) What are the facts?




The parents appear genuinely concerned Exam: The doctor orders clinical tests to rule out organic causes Taking immediate action reassures the parents and suggestions for reversing any deficits are instituted

Labs:

Contacting the social worker will give you more information and put the family at ease Table 3.1.2 Populated tables for Case Vignette 3.1.2 (continuation) What are the facts?


Peter is in the fifth percentile in height and weight

Organic causes Anaclitic depression


PMH: He is adopted from Romania FH: The social worker agrees that there are commonly non-physical medical deficits

SH:

Although orphanages are screened, the need for health care is overwhelming

Exam:

Including the social worker will broaden the health care team and provide better care

Labs:



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Table 3.1.3 Populated tables for Case Vignette 3.1.3 (continuation) What are the new facts?



Mr. and Mrs. Magellan sound like they are making extreme efforts to interact with Peter

Anaclitic depression An enriched environment is responsible for amelioration of developmental deficits

HPI:

Peter is starting to respond to the attention with smiles and wanting his favorite foods


PMH: FH: SH:

Exam:

There is no evidence that Peter has an organic illness The parents appear relieved that Peter is responding positively Peter is scheduled to come into the office again in 5 months.

Labs:


After 6 months of a balanced diet and an enriched home life, Peter seems to be reaching his developmental milestones in the areas of motor control and social skills

How do these facts help rule in or rule out previous hypotheses, and what are new hypotheses? The enriched environment and balanced diet is abating several of the developmental milestone delays Peter may be delayed in communication because of the apparent neglect he suffered at the orphanage; alternatively, Peter may be suffering communicative delay because he was not exposed to English for 2 years


PMH:

FH:

SH:


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Table 3.1.4 (continued) What are the new facts?

How do these facts help rule in or rule out previous hypotheses, and what are new hypotheses?

Peter is still unable to communicate with words, but is able to point



Exam:

Peter remains very slight according to the American CDC growth curves

Labs:


Three years have passed since implementing an enriched environment for Peter and he is thriving

How do these facts help rule in or rule out previous hypotheses, and what are new hypotheses? Peter is currently of sufficient height and weight to not be too concerned Peter does not appear delayed in any of the areas in which he was initially


PMH: FH:

Peter is now able to communicate with his family and strangers Peter remains slight according to the American CDC growth curves, but has gained enough weight and height to reach the 25th percentile

SH:

Exam:

Labs:



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Table 3.2.1 Populated tables for Case Vignette 3.2.1 Jane and Sarah Jones What are the facts?



Sarah and Jane are identical twins

Organic causes—lead exposure, iron deficiency anemia, B12 deficiency

HPI:

The pregnancy and delivery were uncomplicated

TORCH infection Birth trauma, anoxic event

PMH: FH:

The girls were raised in different environments

Vision or hearing deficit Depression Adjustment disorder

SH:

There is no evidence that Jane is ill The mother appears genuinely concerned


Exam: Attention deficit disorder Labs: Labs and vision and hearing screening to rule out organic causes


Labs show genetically identical twins with no genetic reason for the difference in cognitive function

How do these facts help rule in or rule out previous hypothesis, and what are new hypothesis? Less likely to be physiologic cause for apparent discrepancy in twin’s cognitive environment

The twins grew up with different environmental influences

Nature versus nurture—can environment influence academic abilties?

Sarah grew up in a more Are certain experiences enriched environment related to improved and was exposed to cognitive function? musical training at a young age

What do you want to know next? HPI: PMH: FH:

SH:

Exam:

Labs:


Chapter 4

Learning Principles of Human Behavior David O. Antonuccio and Amber Hayes

Behavioral principles are powerful predictors of human behavior. When health care professionals understand these principles, they can be applied to changing health behaviors. In this chapter, we review the principles, which many of the readers will be familiar with from undergraduate and graduate classes. We apply the principles to PBL cases to illustrate behavioral principles in medical care. At the end of this chapter, the reader will be able to 1. Define the important behavioral terms such as classical conditioning, operant conditioning, reinforcement, reward, punishment, reinforcement schedule, antecedents, consequences, stimulus control, modeling, and functional analysis 2. Apply behavioral principles to some common behavioral problems observed in medicine 3. Develop treatment plans for some common behavioral problems using behavioral principals

Case Vignette 4.1.1 Presenting Situation: Richard Smith Richard Smith is a 58-year-old man who comes to see you, his primary care physician, for an annual exam. During the routine interview, you ask about tobacco use. He admits to being a smoker and smoking two packs of cigarettes per day for the last 40 years. Richard states that he wishes he could “quit this nasty habit,” but has had difficulty in the past.


D.O. Antonuccio Professor of Psychiatry, University of Nevada School of Medicine


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D.O. Antonuccio, A. Hayes

Case Vignette 4.1.2 Continuation When you ask Richard why he wants to quit now, he says that he has been hearing about all of the bad health effects of smoking. His wife has been nagging him whenever he smokes because she is worried about his health so he has been sneaking cigarettes behind her back and now he feels guilty about this. Richard will soon be a grandfather and he is worried about the potential effects of second-hand smoke on babies. He also wants to make sure he is around to enjoy his grandchildren growing up. In the past, Richard says he has tried stopping “cold turkey,” but the withdrawal symptoms and cravings drove him back to smoking after about 3 days.


Learning Issues Functional Analysis You request the patient perform a functional analysis of his smoking. A functional analysis is a systematic way to characterize a behavior by examining events that happen prior to (i.e., antecedents) the unwanted behavior (in this case, smoking) and the consequences of acting out that behavior. Richard will record each cigarette he smokes and the activities leading up to the cigarette to find out what types of triggers or antecedents cause him to want to smoke. Smoking a cigarette has been paired with some environmental stimuli many hundreds of times, causing them to become classically conditioned. For example, a patient who smokes after a meal to satisfy a craving may find that he has an urge to smoke after all meals. You also ask Richard to make a list of the consequences of smoking to help understand the role of operant conditioning. Not all consequences are bad, for example the feeling of relief after having smoked. Some consequences are powerful reinforcers, i.e., increase the probability of smoking.

Case Vignette 4.1.3 Continuation Richard returns to your office 1 week later with a daily log of cigarettes and activities. Table 4.1 lists some antecedents and consequences for his smoking and identifies them as punishing (any consequence that makes smoking less likely) and reinforcing (any consequence that makes smoking more likely). You notice that Richard has a cigarette upon waking, with morning coffee, after every meal, while

4 Learning Principles of Human Behavior

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Table 4.1 Functional analysis of Richard’s smoking Antecedent

Consequence

Punishing (P) versus reinforcing (R)

Waking On phone Coffee After meal Driving Visiting with friends

Feeling relieved Wife nags him Costly Smoker’s cough Satisfies boredom Feeling socially accepted

R P P P R R

driving, while on the phone, and while visiting with other smoking friends. Except for one cigarette, he smokes outside of the presence of his wife. Though her nagging serves as a punisher for his smoking, he feels resentful and tends to avoid talking to her about his smoking. You point out that by definition, punishment decreases the probability of a behavior but does not encourage appropriate alternatives. This may be why he feels angry and then avoids his wife. You invite Richard’s wife to the session to educate her about the downside of nagging and other punishment and encourage her to be supportive or at least neutral when he is struggling with his smoking.


Learning Issues Stages of Change The stages of change can be seen in just about any behavior that one wants to modify including behaviors such as eating habits, compliance with treatment, and addiction (Zimmerman et al., 2000). The stages are divided into five phases: precontemplation, contemplation, preparation, action, and maintenance (DiClemente et al., 1991). It is important to note that a person may fluctuate back and forth between stages as they consider changing a particular behavior. Understanding a person’s current stage will guide your treatment approach. Most smokers will exhibit the stages of change as they attempt to quit smoking. Precontemplation stage. In this stage, one is not even considering changing the behavior. To assist people in this stage, it is appropriate to recognize and validate their unwillingness to change at this time, provide personalized reasons that the behavior puts them at risk, and provide an opportunity to revisit the idea of changing the behavior in the future.

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Contemplation stage. In the contemplation stage, the idea of the behavior being a problem has crossed the person’s mind more than once, but currently he or she lacks lack the commitment to take action. To assist people in this stage it is often helpful to make a list of “pros and cons” for continuing the behavior versus changing it. It is also important to highlight the benefits of changing. Preparation stage. A person in the preparation stage has begun to “test the waters” and is much more serious about changing and developing a plan to change in the near future. A person in this stage will actually set some specific goals or target dates. To assist a person in this stage you can help him or her to identify possible roadblocks to changing the behavior, set up a support system, and identify “next steps” for changing the behavior. Action stage. The action stage has begun when the person begins modification of the behavior. This may require assistance in changing the normal cues for the undesired behavior, continuing to build the support system and identifying obstacles to maintaining the change. It is important to note that persons in this stage may begin to feel a sense of loss for the old behavior. Maintenance stage. In the maintenance stage, the behavior has been modified for some time but requires continued work to prevent a relapse. Your role is to help identify the situations in which a relapse could occur and as a team decide on how best to overcome them. It is important to stress that the occurrence of a relapse does not mean instant failure—more than likely it provides a learning opportunity for the future. FYI: Smoking Cessation Tools (Table 4.2) Table 4.2 The 5 A’s approach to smoking cessation The 5 A’s approach The U.S. Public Health Service recommends the “5 A’s approach” to treatment of smoking (Fiore et al., 2000): Ask about tobacco use. This also involves addressing myths about quitting. For example, it is a myth that past attempts decrease ability to quit or that older smokers do not benefit from quitting Advise users to stop. Provide the patient with information on the medical benefits Assess willingness to quit. An important factor is to match the intervention with the stage of quitting (see below) Assist in quitting Arrange for follow-up (This five-step program could easily be adapted to any kind of habit change a physician is encouraging in a patient)

Case Vignette 4.1.4 Conclusion Richard asks you what he should do next. You ask your patient if he is ready to pick a target quit date. He chooses his wife’s birthday in 3 weeks. You suggest that he practice not smoking before his quit day by eliminating smoking during one of the easier situations he has identified. Richard decides to become a nonsmoker while


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driving his car. He plans to keep his cigarettes in the trunk of his car and to put sugarless candy in his ashtray as a substitute to help him achieve this goal. This is called a stimulus control strategy, i.e., altering the environment to make it easier to disconnect the stimulus of driving from the behavior of smoking. By altering some of the environmental stimuli, hopefully, he can reduce his smoking (Antonuccio, 1992). Richard comes back to see his physician weekly to evaluate his progress and for support. On his wife’s birthday, he begins using the nicotine patch you suggested. He chooses to reduce his patch each week so that 3 weeks after his quit date (e.g., Bolin et al., 1999) he is totally nicotine-free. He feels proud of himself and his wife tells him it is the best birthday present she has ever received.

Case Vignette 4.2.1 Presenting Situation: Samantha Brown Samantha Brown is a 48-year-old woman who comes to the clinic today because of sleeping problems. She states that over the last 3 months she has not been sleeping well at all and wonders if there is anything that can be done.


Case Vignette 4.2.2 Continuation You take a sleep history using the BEARS (Bedtime, Excessive daytime sleepiness, Awakenings, Regularity and duration of sleep, Snoring) acronym. First you review bedtime rituals and what happens at sleep onset. You ask about the use of alcohol, nicotine, caffeine, and medications. You ask about how tired she gets during the day. Other questions you ask are, how well she sleeps through the night, how many hours of sleep she typically gets, and about snoring. You ask Samantha to keep a log of her daily activities, emphasizing her nightly rituals before, during, and after sleep. Her log shows that she is having difficulty falling asleep and staying asleep. She details that it takes her over an hour to fall asleep and then she wakes up a short time later. Her average evening includes getting home from work at approximately 6 p.m. Then she usually goes to the gym and exercises on the elliptical machine for an hour. When she returns home, it’s usually about 8:30 p.m., and she will have her dinner. At dinner, she usually tries to unwind by having a glass or two of wine. After dinner, she showers and goes to bed but notes that every night she feels as though she is not tired and often lies in bed thinking of tomorrow’s duties and errands. To try to fall asleep, she will turn on the television and have another glass of wine. After approximately 1 hour she will fall asleep, but later at 3 or 4 a.m. she will be wide awake and have difficulty falling back asleep. Her alarm usually goes off about 6 a.m.

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Case Vignette 4.2.3 Conclusion You explain to Samantha that there are many causes of insomnia and that often they are the result of our own activities (antecedents) during the day. She is given a Sleep Hygiene handout that explains which activities, like exercising late and alcohol use, can lead to the adverse consequence of insomnia. You also discuss how her mood can influence her sleep. You ask her about her mood lately and if she has had any feelings that are consistent with depression. Samantha answers no, except to a question on worrying often. Instead of worrying about the next day while lying in bed, you suggest setting aside some “worry time” in which she can think over tomorrow’s events and current stresses before she starts her bedtime rituals. You also ask her not to go to bed until she is actually sleepy in order to restrict her time in bed to actual sleep time. This is a stimulus control strategy to help make the bed a stimulus primarily for sleep. You suggest that she get out of bed if she is unable to fall asleep within 20 minutes. You also suggest that she get up at the same time each morning no matter what time she falls asleep the night before to help condition her body to waking up on a regular pattern. In fact, you would like her to look toward the horizon (not directly at the sun) each morning to get her biological clock started with broad spectrum light. In addition to limiting her alcohol intake, you ask Samantha to avoid caffeine after 6 p.m. You also suggest keeping her bedroom cool, dark, quiet, and conducive to sleep. You congratulate her on her exercise routine but advise never exercising less than 3 hours before she is planning to go to sleep. You reassure Samantha that most people don’t actually need a full 8 hours of sleep per night to function adequately and even after a night of insomnia she is not likely to feel impaired all of the next day. Samantha decides to start her exercise routine in the morning. She also makes a commitment to limit her alcohol consumption to no more than one glass of wine before 7 p.m. on any given evening. She returns to your office after 1 month of adjusting her choices throughout the day, and the result is that she now is sleeping much better.

Case Vignette 4.3.1 Presenting Situation: Dennis You are the pediatrician to Dennis, a 4-year-old boy with lots of energy. He is smart and is the only child in a loving family of older parents who are grateful to have him after years of infertility interventions. He is their “miracle baby.” His parents have


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expressed the desire not to spoil him but they fear that they already have. He plays well with other children at preschool and his preschool teachers do not report any behavioral problems. Dennis’s parents are happy he is adjusting well to preschool but they are concerned about some of his behavior when he is at home. They report that several times a week he will have a “melt down” during which he will throw a verbal and physical tantrum, often rolling on the floor screaming.


Case Vignette 4.3.2 Continuation You request that Dennis’s parents perform a functional analysis of their son’s tantrums. After tracking the behavior for a week, the parents discover that he had three tantrums at the supermarket. A careful analysis of the tantrums revealed that it is common for Dennis to go shopping with his mother at the local supermarket and find a toy or candy that he wants. When his mother tries to say no, he will cry. If she continues to say no, he will escalate and start to throw a tantrum. If she continues to resist, he will often escalate to falling on the ground and screaming. At this point, his mother feels acute embarrassment and will do anything to make it stop, including giving him the toy or candy. He then quickly calms down and a smile returns to his face. Then his mother quickly leaves the store red-faced with the purchases. What are the antecedents and consequences of their son’s behaviors? What consequences would be properly characterized as punishers or rewards? How would you characterize the reinforcement schedule for the tantrums?


Case Vignette 4.3.3 Continuation Dennis’s parents learn that they are continuously reinforcing their son’s tantrums by giving him what he wants until he calms down. This is a pattern they would like to change. They also learn that Dennis is negatively reinforcing his mother’s giving in to him by stopping the tantrum as soon as she gives in to his demand and agrees to buy the candy or toy. In other words, the child stops the aversive tantrum (negative) whenever the mother gives him what he wants, thereby increasing the

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mother’s behavior of giving in. By definition this is negative reinforcement of the mother’s behavior. The parents learn that his preschool uses a system called 1-2-3 Magic (Phelan, 2004). This system involves giving the child a warning when his behavior is disruptive by telling him “You are on one.” If he does not comply with the request, he is told, “You are on two.” If he still does not comply with the request, he is told “You are on three” and there is a negative consequence of some kind. At school the negative consequence is sitting quietly by himself in a time-out room for 3 minutes. His parents unobtrusively observe the teachers model these techniques in the classroom. One of the teachers is an especially good model because she herself also struggled with her own child’s tantrums issues and can relate to the parents’ struggles. This teacher had to work at learning the system with her own child by practicing it repeatedly in the classroom. In that sense, she is a coping model (i.e., someone who had to learn to cope), an even more powerful model than a mastery model (i.e., someone for whom reward and time-out comes naturally). Models are also more effective if they are similar to the person observing, they are skillful in their implementation of the target behavior, they are attractive, and there is opportunity to practice the target behavior. Dennis’s parents decide to use this system and make the consequence a 3-minute time-out in the corner of whatever room they are in. If he comes out of time-out, he will lose the privilege of dessert after dinner. His parents decide to build in some flexibility for him to earn back dessert with good behavior like helping his mother with a household chore. To reduce her embarrassment, Dennis’s mother talks to the store manager and lets him know that she is trying to do a better job of setting limits with her son when he is in public. The store manager, who is also a parent, is completely sympathetic and understanding. He says it is fine with him if her son has a full-out tantrum on the next trip to the store and he supports her setting appropriate limits. He agrees to alert the cashiers of her plan the next time she comes in. She lets him know she will come in later that afternoon after preschool. What would you expect to happen the next time Dennis’s mother goes shopping at the store with him? Dennis’s mother explained to Dennis the new system of discipline she was planning to implement. She takes him shopping that afternoon as planned. The store manager gives her a wink when she arrives. Dennis finds some M&M candy-coated peanuts and within 5 minutes he is asking his mother for the candy. She says “No” because it will spoil his dinner. He begins to cry and it gets louder. She tells him he is “on one.” He escalates to falling on the floor. She tells him he is “on two.” He begins screaming, and she tells him he is “on three” and must sit on the floor in time-out until he calms down and that under no circumstances can he have M&Ms today. He screams louder and keeps it up for about 3 minutes, much longer than he usually does when she gives in to his demands. This is called an extinction burst, i.e., a burst of behavior following the withdrawal of an expected reinforcer. She tells him that when he is calm for 30 seconds, he can come out of time-out. Another mother whispers to her that she is totally supportive and admires her limit setting. Eventually Dennis calms down and they leave the store together holding hands. The mother, though still somewhat embarrassed, is proud of herself for sticking to her boundary.


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Case Vignette 4.3.4 Conclusion Dennis’s mother implements the same strategy the next time she goes to the store and notices that Dennis’s tantrum only lasts about 30 seconds. The third time in the store together he doesn’t tantrum at all. His tantrum behavior is extinguishing.

Case Vignette 4.4.1 Presenting Situation: Nana Phyllis White (“Nana”) is a 75-year-old grandmother who loves to come to Reno to gamble and visit her adult grandson, in that order. Her grandson is concerned because she goes from casino to casino in a bus with her fellow senior citizens but doesn’t even take time out to eat sometimes. Her favorite game is the pull slot machine. She feels she is getting good exercise but her grandson is concerned that she can’t afford to spend long hours gambling in smoky rooms, both physically and financially (Unwin et al., 2000).


Case Vignette 4.4.2 Continuation You are a family medicine doctor who has been working with Phyllis on general health maintenance and treatment of arthritis and acid reflux. You meet with her and her grandson at his request and learn of the concerns about the trips to Reno. You ask Phyllis to track her gambling behavior and to write down exactly what games she plays and exactly how much time she is gambling. You also ask her to write down other activities she enjoys on her trip to Reno. You find that she gambles as much as 20 hours on a 2-day trip to Reno. Although she does not skip any meals, she does delay them sometimes. She also enjoys seeing her grandson and his young children play baseball when they have a little league game scheduled.

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Case Vignette 4.4.3 Conclusion In an application of the Premack Principle, you encourage her to socialize with her grandson and his children before she goes gambling at the casino with her friends. In order to accomplish this, she stays at her grandson’s house instead of the casino. After a morning brunch and afternoon baseball session, her grandson drops her off at a casino with her friends from about 7 p.m to 9 p.m. After that she is ready for bed. Her tracking shows that she has reduced her gambling from 20 hours per weekend visit to only 5 hours. She has more quality time with her grandson and great grandchildren in the process.

Learning Issues 1. Premack Principle The Premack Priniciple (named for the theorist David Premack) is that animals have baseline levels of engaging in different behaviors (e.g., eating, drinking, running, playing). The Premack Principle postulates that humans and other animals will work at a less probable behavior for the opportunity to engage in a more probable behavior. In this case, Phyllis collaborated with you to plan to do other things that were important to her, like spend time with her grandson and great grandchildren and get proper nutrition, before she allowed herself her guilty pleasure of gambling. This is an important and simple principle of self-reinforcement, i.e., work before play or eating vegetables before dessert. 2. Reinforcement schedules The pattern of reinforcement is called a reinforcement schedule (Beaton, 2001). Reinforcement schedules can vary according to the number of responses before a reward is delivered (ratio schedule) or in the time elapsed between rewards (interval schedule). A ratio schedule or an interval schedule can be fixed or variable. In a fixed ratio schedule, a reward is delivered after a certain number of responses. For example, a factory worker might receive a bonus for every 10 cars manufactured by his or her team. In a variable ration schedule, a reward is delivered after an average number of responses. For example, the slot machines that Phyllis enjoys are usually set to deliver a payoff after an average number of pulls. Ratio schedules tend to result in a high response rate and a variable ratio schedule results in a pattern of responding that is the most resistant to extinction (i.e., a dropping off of the response when the reinforcer is removed).


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Receiving a paycheck every 2 weeks is an example of a fixed interval schedule. A variable interval schedule might involve a fisherman who catches his limit of 10 fish over the course of 5 hours of fishing. Some of the fish are caught within 5 minutes of each other while others might be caught several hours apart. 3. The neurobiology of reinforcement The neurobiology of anticipation, reward, and reinforcement has been studied at molecular, cellular, genetic, systems, behavioral, and computational levels. Though there are still many things we do not understand about the neurobiology of human learning, research in this field is richly productive and rapidly expanding. The neurobiology of addiction (see Chap. 20) appears to be pathologic use of the same brain structures as normal behavioral adaptation (seeking food, water, and opportunity to mate). These structures are collectively referred to as the “mesolimbic reward circuit” and utilize dopamine primarily as the neurotransmitter or chemical messenger (Haynes, 2004). This circuit is composed of dopamine-producing neurons of deep brain structures (the ventral tegmentum that forms projections to the nucleus accumbens and amygdala) and the prefrontal cortex (Vetulani, 2001). We can better understand normal behavior by dividing the behavior systems of the brain into three major categories: arousal, reward, and cognitive systems. The arousal system is further subdivided into general arousal (regulating overall central nervous system excitability) located in the ascending reticular system, directed or goal-oriented arousal (providing motivation and emotion) located in the hypothalamus and parts of the limbic system, and peripheral arousal (linking up the brain to other organ systems) made up of the autonomic nervous system and hormonal systems. All of these systems interact to allow the organism to adapt to the environment although the directed arousal system is involved most substantially in voluntary behavior. The directed arousal system provides a ranking of goals and initiates the behavior needed to attain the goal and then processes whether or not the goal was met. If these goals aid in the organism’s survival or survival of the species, it is properly rewarded and we say that the goal is reinforced. In the case of the brain, this reward is dopamine (Vetulani, 2001). Research has also shown that dopamine is released at a basal tonic rate in anticipation of a previously received pleasurable, reinforcing event, such as sugar water presented to monkeys after a paired stimulus. If the reward is given sooner than expected, it is perceived as “better than expected” and there is a burst of dopamine release. If there is no reward when one is expected there is a pause in the dopamine release indicating “worse than expected.” It is believed that these bursts and pauses of dopamine release encode a “prediction-error signal” that will help the animal to learn the new relationship and reinforce behavior that results in the reward. This is termed the “Reward Prediction-Error Hypothesis.” With addictive drug intake, the signal may be always “better than expected,” resulting in an overriding of all other goal-directed behavior (Hyman, 2005). Better understanding of these brain mechanisms may open doors in the future for treatment of drug addiction as well as other behavioral problems.

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Review Questions 1. Two new parents wake up quickly to the sound of their 1-year-old baby crying in the middle of the night. Every night when this occurs, they immediately bring the baby to bed with them to comfort her. The baby immediately settles down to sleep. This is an example of (a) (b) (c) (d) (e)

Intermittent reinforcement Extinction Continuous reinforcement Shaping Successive approximations

2. A resident observes a skilled surgeon conducting a heart bypass. Based on what you learned about MODELING in the text, the likelihood of learning and retention is UNRELATED to (a) (b) (c) (d) (e)

The attractiveness of the surgeon The practice opportunities for the resident The manual dexterity of the resident The acclaimed skill of the surgeon The age of the surgeon

3. Pick the FALSE statement about punishment: (a) Punishment does not teach appropriate behavior. (b) The punisher (i.e., the person doing the punishing) may model verbal or physical aggression. (c) The punisher may increase the target behavior (i.e., the behavior that is being punished). (d) People learn to avoid the punishment. (e) Punishment tends to generate more emotional behavior. 4. In behavioral approaches to treatment, behavior is thought to be UNRELATED to (a) (b) (c) (d) (e)

Reinforcement history Current contingencies Genetic endowment Ego functioning Reinforcement schedule

5. A patient notices some anxiety while driving following a serious car accident. She notices some relief of her anxiety if she avoids driving on the freeway, causing her to avoid freeway driving entirely. The relief of anxiety she experiences from avoiding freeways is an example of (a) Negative reinforcement (b) Positive reinforcement


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(c) Punishment (d) Conditioned stimulus (e) Generalized reinforcer 6. An adult patient comes to you with stomach pain that does not appear to have an underlying biological basis. You decide to use your skills in functional analysis to help correct the problem. You ask the patient to (a) Keep track of their dreams. (b) Focus on available punishers in their environment. (c) Keep track of the antecedents of the pain, the pain itself, and what happens after the pain occurs. (d) Take an in-depth history of childhood, focusing on toilet training. (e) Focus on cognitions, and reward systems in the environment. 7. Behavior analysis is characterized by all EXCEPT one of the following: (a) (b) (c) (d) (e)

Identifying antecedent events Evaluating consequences Measuring duration of behavior Determining a DSM-IV diagnosis Measuring the frequency of behavior

Answers 1. c, 2. e, 3. c, 4. d, 5. a, 6. c, 7. d

Possible Answers to Behavioral Principles Tables Case table 1.1 Richard Smith 1 Facts

Hypotheses

58-year-old-male 80 pack-year smoker wants to quit

Given the patients extensive heavy smoking history, he will need lots of assistance to quit

Information needed Why does he want to quit now? What has RS tried in the past? When does he usually smoke? What is his longest period of prior abstinence? How does he deal with stress?

Learning issues Principles of functional analysis

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Case table 1.1 (continued) Facts

Hypotheses

Information needed What is the functional relationship between the patient’s environment and his smoking?

Learning issues

What are typical antecedents to smoking for this patient? What are the typical consequences of smoking for this patient? Case table 1.2 Richard Smith 2 Facts R.S. identifies the antecedents and the consequences

Hypothesis Information needed Changing the What type of antecedent behavior follow-up plan will may change the he need? likelihood of smoking

Learning issues Stages of change Smoking cessation tools

Case table 2.1 Samantha Brown 1 Facts 48-year-old female complains of insomnia for 3 months

Hypotheses Possible medical reason? Possible stress? Mood disturbance? Substance use?

Information needed What part of sleeping does she have trouble with?

What is her bed-time routine like?

Learning issues How to take a sleep history

Typical antecedents for a good or poor night of sleep What are the consequences of a good or poor night of sleep

Case table 2.2 Samantha Brown 2 Facts Difficulty falling asleep Difficulty staying asleep

Hypotheses Information needed Learning issues Changing her How does the patient’s Sleep hygiene causes routine may have an sleep change after for insomnia impact the intervention?


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Case table 2.2 (continued) Facts Antecedent behaviors include exercising late, eating late, alcohol intake, staying in bed and worrying, and watching television in bed

Hypotheses

Information needed

Learning issues

Hypotheses Information needed Parents actions are What type of reinforcing tantrums activities lead to tantrums (antecedents)?

Learning issues Reinforcement schedules

Consequences include feeling fatigued the next morning and inability to concentrate at work

Case table 3.1 Dennis 1 Facts 4-year-old boy

Parents complain of tantrums No problems in school

How do the parents react to the tantrums (Consequences and reinforcers)?

Plays well with peers

Case table 3.2 Dennis 2 Facts Antecedents to their son’s tantrums: Dennis sees a small toy or piece of candy he wants Dennis realizes he is in a public place that will be embarrassing for mom if he throws a fit

Hypotheses Changing the consequences may alter the behavior

Information needed What happens to the behavior after implementing the intervention?

Learning issues Reinforcement schedules What are some tools to modify behavior in children?

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Case table 3.2 (continued) Facts Consequences of his tantrums: Mom gets embarrassed by Dennis’s tantrum Mom gives him the toy or candy he wants and Dennis calms down immediately

Hypotheses

Information needed

Learning issues

Case table 4.1 Nana 1 Facts 75-year-old female grandson concerned about gambling to point of exhaustion

Hypotheses Gambling may be out of control

Information needed How much does Nana actually gamble?

Reinforcement schedule of slot machines makes it difficult to extinguish the gambling behavior

How much time does she devote to gambling? Does she skip meals?

Learning issues Gambling addiction

Reinforcement schedules of slot machines

What else does she like to do besides gambling?

Case table 4.2 Nana 2 Facts 20 hours in 2 days

Delays meals

Enjoys seeing her grandson and watching his young children play baseball

Hypotheses Using gambling as a consequence for other activities like adequate socialization and nutrition will help her have better balance

Information needed What happens to Nana’s gambling after the intervention?

Learning issues Premack principle

Reinforcement schedules


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References Antonuccio, David O. (1992). Butt out, A Compassionate Guide to Helping Yourself Quit Smoking, with or Without a Partner. R&E Publishers, Saratoga, CA. Beaton, J.M. (2001). Learning Theory and Human Behavior in Behavior & Medicine, edited by D. Wedding. Hogrefe & Huber Publishers, Toronto. Bolin, L., Antonuccio, D.O., Follette, W., and Krumpe, P. (1999). Transdermal nicotine: the long and the short of it. Psychol. Addict. Behav., 13, 152–156. DiClemente, C.C., Prochaska, J.O., Fairhurst, S.K., Velicer, W.F., Velasquez, W.F., and Rossi, J.S. (1991). The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J. Consult. Clin. Psychol., 59, 295–304. Haynes, Thomas L. (2004). The Neurobiology of Addiction and Its Implications for Treatment— Drug-Seeking Behavior and the Transition to Dependence. http://www.medscape.com/ viewarticle/472498. Hyman, Steven E. (2005). Addiction: “A Disease of Learning and Memory.” Am. J. Psychiatry, 162, 1414–1422. Phelan, T.W. (2004). 1-2-3 Magic: Effective Discipline for Children. Parent Magic Inc. Unwin, B., Davis, M., and DeLeeuw, J. (February 1, 2000). Pathologic Gambling. AFP, 61(3). Vetulani, Jerzy (2001). Drug addiction. Part II. Neurobiology of addiction. Pol. J. Pharmacol., 53, 303–317. Zimmerman, G., Olsen, C., Bosworth, M. (March 1, 2000). A stages of change approach to helping patients change behavior. AFP, 61(5).

Chapter 5

Sexuality Throughout the Life Cycle Kevin Allen Mack and Anthony P.S. Guerrero

There are few topics in medicine that blur the boundaries of science and morality more than sexuality. The “culture war” keeps our courts busywith cases involving hate crimes, marriage equality, and gay-lesbian-bisexual-transgender (GLBT) rights, while churches, synagogues, and mosques look for ways to interpret the ancient writings and instruct their faithful. Public health departments and state governments construct databases to capture information about persons and practices that may inadvertently transmit HIV. This chapter aims to provide a basic discussion on sexuality throughout the life cycle. At the end of this chapter, the reader will be able to 1. Distinguish between the terms: sex, gender, gender identity, and sexual orientation 2. Identify normal sexual development in children, adolescents, and adults 3. Describe the human sexual response cycle 4. Discuss issues in sexuality for elderly and medically ill patients

Case Vignette 5.1.1 Baby Pat As a busy family physician in a diverse community, you are called by the certifiednurse-midwife to see Baby Pat, a newly born infant who was noted, at birth, to have ambiguous genitalia. No additional pre- or perinatal risk factors were identified. The family histories of both parents were negative for any prior genetic abnormalities. The patient’s vital signs and physical exam were entirely within normal limits with the exception of the genitourinary exam, which showed a 1 × 1 cm phallus. Labioscrotal folds were present bilaterally, with some hyperpigmentation and rugae. A perineal opening was present. No gonads were palpable in the labioscrotal folds.

K.A. Mack Assistant Professor, University of California, Berkeley/San Francisco A. Guerrero, M. Piasecki (eds.), Problem-Based Behavioral Science and Psychiatry, C Springer Science+Business Media, LLC 2008

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With the assistance of a pediatric endocrinologist, you obtain laboratory studies, which yield the following results (with normal range in parentheses): Electrolytes: Sodium = 127 mmol/l (132–142)∗ Potassium = 6.4 mmol/l (4.0–6.2)∗ Chloride = 94 mmol/l (95–110)∗ CO2 = 21 mmol/l (18–27) Glucose = 66 mg/dl (60–115) Calcium = 9.0 mg/dl (8.0–10.5) Capillary blood gas (CBG): normal Urinalysis: Clear, straw colored Specific gravity = 1.003 (1.007–1.030), pH 8.0 (4.5–8.0), otherwise normal Urine chemistries: Sodium = 24 mmol/l (0–40) Potassium = 13.1 mmol/l (7.0–18.1) Chloride = 21 mmol/l (2–9)∗ 17a-OH progesterone: 11,767 ng/dl (0–200)∗ Other steroid studies: Cortisol—decreased 24-hour urine for pregnanetriol—increased 24-hour urine for 17-ketosteroids—increased Plasma testosterone—increased Plasma dehydroepiandrosterone—increased Plasma renin—increased Plasma and urine aldosterone—decreased Ultrasound of pelvis: Confirms presence of uterus and ovaries Karyotype: XX female State-required PKU and hearing tests for newborns were entirely normal. You review the laboratory studies with the family and begin answering their questions about whether they have a “girl” or a “boy,” and whether their “son” or “daughter” will be “normal” and what impact this condition will have on the child’s future sexual orientation.

Please proceed with the problem-based approach! The industrious PBL student will have little problem identifying the likely diagnosis for this clinical presentation. More challenging, however, will be identifying the clinical and social science issues that will need to be addressed from the

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very onset of the child’s presentation to caregivers. What is at issue here? The child’s sex? The gender? The sexual orientation? How much family education needs to occur to facilitate an informed medical decision regarding the child’s treatment? What is the role of the family’s values in directing the medical intervention? Is there sufficient consensus about the relationship between sex determination, gender identity, and sexual orientation to constitute a “standard of care” for this child? At this point, while a complete discussion of the biology of sex determination is beyond the scope of this chapter, it is worth reviewing a few basic definitions, which are summarized in Table 5.1. While these terms may seem relatively straightforward, sexual development is complex enough to be associated with various concerns and questions that may be presented to the physician throughout the life cycle of a patient.

Case Vignette 5.2.1 Mike In your outpatient practice, you see children of all ages. One of your patients is Mike, a 6-year-old boy, who is brought in by his mother because of “behavior problems in school that might cause him to get kicked out.” According to the principal, he once exposed his penis to a group of his male and female classmates in the playground. While the other children found what he did to be outrageously funny, several parents lodged complaints that they would pull their children out of this school if the teachers couldn’t contain the “immorality” of “other troubled children.” He also tends to make “lewd comments” about people depicted in bathing suits in various magazines.


Following awareness of gender identity, and with the further strides in cognitive development that occur at around the preschool age, children become naturally curious about matters pertaining to sex and sexual organs. Common behaviors include sexually themed play, exploration of one’s own body and the bodies of others, and enactment of adult sexual roles (e.g., being mommy or daddy), often within the safety of the family. While many of these behaviors are “normal” (as is often the best choice in multiple-choice exams on sexual development), the clinician should certainly consider other conditions and situations that may predispose to behaviors that are either quantitatively or qualitatively inappropriate for the given age of development. Consider Table 5.2.

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Table 5.1 Basic definitions

Term

Definition

Chromosomal sex

Whether the human is male (XY) or female (XX)

Assigned gender

Whether a baby is identified as a girl or boy, usually based on the appearance of genitalia

When determined or manifested At conception

Traditionally at birth, though determinable in utero with ultrasound technology

Mechanism of determination Fertilization: fusion of mother and father’s genetic material

Expression of genes and action of hormones that influence the development of sexual organs

Examples of clinical concerns relevant to this concept Phenotypic males with multiple copies of either the X or the Y chromosome

Phenotypic females with either three or more copies of the X chromosome or only one X chromosome Androgen insensitivity syndrome (genetic male with tissues unresponsive to male hormones; hence with female-appearing genitalia)

Congenital adrenal hyperplasia (genetic female with overproduction of androgens; hence with male-appearing or ambiguous genitalia), illustrated in the case above Numerous other intersex conditions: while it had been traditionally taught that sexual reassignment surgery should occur before gender identity (defined below) is established, the implications of this condition are much more complex because of the reality that sexual behavior is determined by more than just the outward appearance of one’s genitalia


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Table 5.1 (Continued) When determined or manifested

Term

Definition

Gender identity

A child’s awareness of being male or female

Usually at around age 2 years

Gender role

Culturally proscribed roles associated with each gender Preference for males, females, or both as sexual partners

Usually by preschool age

Sexual orientation

Usually by adolescence

Mechanism of determination Likely complex interplay between awareness of assigned gender, what is taught and reinforced by caregivers, and biological influences on sexual brain development What is taught and reinforced by caregivers and the community Genetic and other biologically mediated influences on development; likely an interplay between biopsychosocial factors

Examples of clinical concerns relevant to this concept In gender identity disorder (described further in Chap. 29), there is discomfort with one’s own gender; may be seen as early as preschool years, and more commonly in boys than in girls

In gender identity disorder, there may be a preference for the roles associated with the opposite gender Psychological distress around either being in roles that are contrary to one’s basic sexual orientation or experiencing the social stigma attached to a non-majority sexual orientation

Case Vignette 5.2.2 Conclusion You talk to Mike and his mother. Mike conveys regret over what he had done and says that he’ll try to be “good” in school. You learn that, while he may have seen some kissing and adult sitcom shows while being babysat by a teenage cousin and her boyfriend a few months ago, he has not had any other exposure to inappropriate sexual material. While your general behavioral screening questionnaire, the 17-item Pediatric Symptom Checklist, suggests that he may have a possible attentional problem, specific questions do not suggest that he has a bipolar, obsessivecompulsive, or pervasivedevelopmental disorder. You provide counseling about

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Table 5.2 Examples of normal and potentially concerning sexual behavior in a preschool or school-age child Examples of probably normal sexual behavior in a preschool or school-age child Fascination and glee with pictures of half-clothed bodies or of people kissing Manually exploring one’s own body or attempting to manually explore the bodies of family members and close friends Masturbation (possibly aided by toys or other objects) that does not appear to be associated with psychological distress or physical injury and that does not interfere with other developmentally appropriate tasks

Examples of behavior that suggest either inappropriate exposure to sexual activity or other psychopathology Detailed knowledge about specific sexual acts Attempted or actual sexual behaviors that involve penetration, propositioning strangers, and other inappropriate sex talk Compulsive masturbation associated with psychological distress and/or physical injury and that is so time-consuming as to interfere with other developmentally appropriate tasks

developmentally appropriate supervision and refocusing on developmentally appropriate tasks. Obviously, what is “normal” sexual behavior is different for different ages and different stages of development. In general, sexual development closely follows development in other areas, including cognitive development, social development, and physical development. Consider the following cases.

Case Vignette 5.3.1 Mary Jane Your next patient is Mary Jane, a 14-year-old high school freshman, who is brought in by her mother, who requests that Mary Jane be tested for HIV and “anything else that can be sexually transmitted,” placed on the “birth control shot,” and given “that new cervical cancer vaccine and anything else that can prevent sexually transmitted diseases.” The mother learned that Mary Jane slept with a boy classmate at band camp and is now worried that she will catch something from “being promiscuous.” Mary Jane explains that she previously had never had sexual intercourse, other than having “experimented” with fondling a close female friend who is lesbian (even though she herself is “straight.”) She denies ever having had any other sexual experiences. Mary Jane comes from a “traditional family” that, she believes, would not otherwise condone any premarital sexual activity or any homosexual behaviors.

Please proceed with the problem-based approach! Adolescence is a time when hormonal influences lead to the development of secondary sexual characteristics and heightened interest in sexual activity. Key


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Table 5.3 Highlights of adolescent development Male physical development Early adolescence

Testicular enlargement Breast bud formation

Middle adolescence Peak in height growth, spermarche Late adolescence

Female physical development

Mature biological sex characteristics

Peak in height growth, generally followed by onset of menses Mature biological sex characteristics

Cognitive and social developments May still have concrete thinking Same-sex peer groups are common Emergence of abstract thought, questioning, and risk-taking Independence, potential commitment to career, stable partner, etc.

milestones in adolescent development (that often are asked about in standardized tests) are summarized in Table 5.3. The influence of hormones, primarily testosterone (in both males and females), leads to heightened sexual interest in adolescence. Statistics suggest that sexual activity, including intercourse, is common in adolescence and should prompt the clinician to assist youth in preventing sexually transmitted disease and unwanted pregnancy. According to the Centers for Disease Control and Prevention (2005) youth risk behavior surveillance, 46.8 % of high school students have had sexual intercourse. Among the 33.9 % of high school students who are currently sexually active, 62.8 % reported that they or their partner had used a condom during their last sexual intercourse.

Case Vignette 5.3.2 Conclusion You examine Mary Jane and find that she is at sexual maturity rating (SMR) stage 4. You perform a pelvic exam with Papanicolau smear and cultures for gonococcus and chlamydia. You also offer blood testing for HIV and syphilis. You insure that her hepatitis B immunizations are up to date and administer the first of the human papillomavirus vaccine series. You counsel her on effective methods of preventing sexually transmitted diseases (including abstinence). Even though the mother states she is “still grieving” over the loss of her daughter’s “sexual innocence,” she is nevertheless very grateful for your care. Sexual development continues to be influenced by developmental issues at other phases of the life cycle, as illustrated by the following case.

Case Vignette 5.4.1 Presenting Situation: Phil Robinson Mr. Phil Robinson is a 58-year-old male with a history of panic disorder and hypertension. He reports that for the past 6 months he and his 49-year-old wife have had sex less and less frequently. While they continued to have a satisfying sex life even

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after the birth of their three children, they have recently had more difficulties getting “in sync” with each other: either she has little sexual interest (which she relates to “pre-menopause”) or she is sexually interested but he has difficulty maintaining an erection.

Please proceed with the problem-based approach! While a decline in libido-promoting hormones may occur in later adulthood for both women and men, healthy sexuality remains an important priority for most older adults. Familiarity with Table 5.4 is often helpful when approaching clinical situations involving the human sexual response cycle. While “normal sexual development” (once again) may be consideredin the differential, the above case may suggest the diagnosis of male erectile disorder in Mr. Robinson and the possibility of a hypoactive sexual desire disorder in his wife. Given Mr. Robinson’s medical history, it would be important to further inquire about the specifics of his health condition and any medications he may be on. Any health condition or medication that can affect any aspect of sexual physiology (including blood supply and innervation to the sexual organs or anything at all related to brain functioning) could be a culprit in any disorder of the sexual response cycle.

Case Vignette 5.4.2 Conclusion In reviewing Mr. Robinson’s chart, you discover that he is currently on a betablocker for hypertension and a serotonin-selective reuptake inhibitor along with a benzodiazepine for panic disorder. He denies any past history of sexual difficulties Table 5.4 Characteristics of the human sexual response cycle

Stage of cycle

Characteristics

Desire

Fantasies

Arousal

Lubrication in female, erection in male

Plateau Orgasm

Resolution

Intensified pleasure, rhythmic contractions, ejaculation in males

Examples of conditions involving this stage of the sexual response cycle Hypoactive sexual desire disorder, sexual aversion disorder Female sexual arousal disorder, male erectile disorder Orgasmic disorder (male and female), premature ejaculation


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other than what he reports as “premature ejaculation” earlier in his adult life. He thinks it is possible that he had more erectile difficulties ever since his serotoninselective reuptake inhibitor dose had been increased. He also believes that the increased anxiety symptoms he had been having around that time (hence the dose increase) may have played a more important role and may have contributed to what he feels may be a “vicious cycle” of performance anxiety around sexual intercourse. You work to optimize his medication regimen and insure that he has no new medical problems. At a future visit, you provide education to him and his wife about the various factors that can affect the sexual response cycle. You encourage Mrs. Robinson to follow up with her physician. In the meantime, you encourage them to focus on enjoying emotional and physical closeness with each other, with a de-emphasis on sexual intercourse. A few months later, he is happy to report that they have enjoyed their sex life once again. Sexual issues are encountered in all specialties of medicine and in patients of all age groups. In this chapter, we have reviewed sexual development throughout the life cycle. A further discussion of clinical disorders that involve sexual behavior is found in Chap. 29.

Review Questions 1. An adolescent girl who presents with primary amenorrhea and otherwise normalappearing pubertal development is found to have an XY karyotype. The most likely diagnosis is (a) (b) (c) (d) (e)

Normal development Polycystic ovary syndrome Congenital adrenal hyperplasia Androgen insensitivity syndrome Turner’s syndrome

2. All of the following patients likely are exhibiting normal sexual development EXCEPT for (a) A married couple in the mid-50s who engage in sexual intercourse several times per week (b) A 5-year-old male who makes two attempts in the office to peek under his mother’s dress (c) A 16-year-old female who presents with flight of ideas, seductiveness toward the physician, and her fifth episode of pelvic inflammatory disease, which she said she caught from “sleeping with the whole football team” (d) A 12-year-old female who is accidentally caught stroking her genital area while in her bedroom (e) An 18-year-old male who presents with a urinary tract infection, which he believes he might have caught from his male partner, whom he has been with for the past year

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3. Which of the following represent the earliest signs of puberty in males and females? (a) (b) (c) (d) (e)

For males: testicular enlargement; for females: breast bud development For males: spermarche; for females: height spurt For males: testicular enlargement; for females: menarche For males: spermarche; for females: breast bud formation For males: testicular enlargement; for females: height spurt

4. Which of the following represents the correct temporal sequence of the sexual response cycle? (a) (b) (c) (d) (e)

Plateau, desire, arousal, orgasm Desire, arousal, plateau, orgasm Arousal, desire, plateau, orgasm Plateau, arousal, orgasm, plateau Orgasm, plateau, arousal, desire

Answers 1. d, 2. c, 3. a, 4. b

Bibliography Bright Futures, Tool for Professionals. Pediatric Symptom Checklist. http://www.brightfutures.org/ mentalhealth/pdf/professionals/ped sympton chklst.pdf. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report Youth Risk Behavior Surveillance—United States, 2005. Surveillance Summaries June 9, 2006/Vol. 55/No. SS-5, http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf. Sadock B.J. and Sadock V.A.. (2003). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th Edition. New York: Lippincott Williams & Wilkins.

Chapter 6

Adaptation and Coping in a Medical Setting Maria-Christina Stewart

Coping adaptively in the face of medical adversity is a critical advantage. This chapter illustrates the importance of adaptive coping and how physicians can help patients develop skills. This chapter, like the sample vignette in Chap. 1, uses graphics in the vignette text to help identify key facts for the PBL process. While this chapter does not cover all of the psychiatric illnesses that may occur following the diagnosis of a medical illness (as these are covered in the specific chapters), it highlights both healthy and potentially unhealthy behaviors. At the end of this chapter, the reader will be able to: 1. Define and identify methods of coping and adaptation 2. Determine neurobiological, psychological, social, and spiritual variables affecting coping and adaptation 3. Classify and distinguish among functional and dysfunctional methods of adapting to and coping with stressful situations such as medical adversity 4. Identify methods of intervention to facilitate adaptive coping

Case Vignette 6.1.1 Presenting Situation: Paul Davis Paul Davis is a 75-year-old African-American male who recently presented with “cognitive difficulties.” Accompanying him at every medical appointment and assisting in decision-making processes is his wife: his number “one supporter” and partner in life. Paul is scheduled today for cognitive testing. He arrives with his wife and shares with you his comfort with end-of-life issues, claiming to be “keeping a stiff upper lip” and endorsing a stoic disposition in the face of stress. During the testing process, his wife leaves to run errands and then returns to bring

M. Stewart Department of Psychology, University of Hawai‘i, Currently a Research Fellow at the Center for Anxiety and Related Disorders, Boston University A. Guerrero, M. Piasecki (eds.), Problem-Based Behavioral Science and Psychiatry, C Springer Science+Business Media, LLC 2008

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him home. Paul is silent during the majority of cognitive testing, including after his wife returns to bring him home.


Adaptation and Coping Defined Adaptation Adaptation refers to efforts and processes aimed at managing demands of stressors. It involves the use of resources, coping, and problem-solving strategies, with the ultimate goal of altering an individual’s state of functioning. As we will see, this new state may be positive or negative (e.g., a positive adaptation of using external resources to aid in coping with cancer may become negative if it is the only process of adaptation employed and the individual does not learn to use inner resources). The process of adapting involves making changes to (Friedman, Bowden, & Jones, 2003):

r r r r r r r

Established patterns of functioning Internal resources Resources within the family and community Appraisal of how demands are being and should be met World views Problem-solving skills Coping methods

Coping Coping refers to problem-specific efforts aimed at preventing, avoiding, or controlling specific external and/or internal stressors that are impairing an individual’s wellbeing (e.g., emotional distress and/or solving problems). More specifically, coping refers to behaviors that can or are being employed, rather than resources that could be of use (Friedman et al., 2003). As patients adapt to and cope with medical visits, diagnoses, and procedures, it is normal for them to experience transient emotions. When such emotions become persistent or uncontrollable, however, they may hinder adaptive coping and adaptation behaviors and result in a psychiatric disorder.

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Table 6.1 Considering the facts, examining hypotheses, and identifying specific information

What are the facts? Age 75 Male Married Cognitive difficulties Receiving cognitive testing Claims to be comfortable with end-of-life issues Stoic disposition Considers wife to be a source of support Silent

What are your hypotheses? 1. He relies on his wife for significant support 2. He is facing and considering end-of-life questions and issues 3. His silence and stoic disposition may be a sign of underlying difficulties in adapting to and coping with his cognitive deficits 4. His silence and stoic disposition may be related to an underlying medical/neurological or psychiatric condition (e.g., major depression, dementia, etc.) 5. Cognitive deficits, in particular, may be difficult for him to accept because of stigma

What specific What do you want to information would you know next? like to learn about? HPI Medication? Sleep? Appetite? Hopelessness? Fear? PMH Has he had any previous medical or psychiatric diagnoses, including substance abuse? FH Any history of psychiatric illness? SH Social support besides wife? Exam Physical exam? Vital signs?

1. How are adaptation and coping defined? 2. What are the major neurobiological and psychosocial correlates of adaptation and coping? 3. How does social support affect adaptation and coping? 4. What are the interventions for coping deficits?

Neurobiological Correlates of Adaptation and Coping As we start to formulate our case conceptualization of Paul and consider which methods of adaptation and coping, if any, he may be employing or may be beneficial (see Table 6.1 to review our problem based approach), let’s keep in mind the physiology behind two primary emotions often associated with medical adversity: fear and sadness (summarized in Table 6.2, for a detailed review, see Carlson, 2006). While a detailed discussion of the physiology of stress is beyond the scope of this chapter and is more comprehensively covered in Chap. 11 (Stress and Health), it is important to consider the ways in which the primary medical illness being adapted to can, in itself, pose a biological risk to maladaptive coping. Table 6.2 Examples of neurobiological correlates of persistent fear and sadness Oversensitive norepinephrine system in the locus coeruleus Abnormal function of serotonin system Over-secretion of corticotropin-releasing factor and subsequent long-term reduction in cortisol Reduction in hippocampal volume

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Effect of Social Support on Adaptation and Coping Support from external sources such as extended social support networks and the community can significantly aid in both adapting to and coping with major stressors through alleviating much of the associated burden and preventing additional stress and negative consequences. Individuals and families with support from social networks tend to cope with medical crises and illness better than individuals or families employing only internal strategies, and absence of social support can engender feelings of vulnerability—especially among individuals whose cultural norms include relying on extended kin for assistance (Friedman & Ferguson-Marshalleck, 1996). As a result, active participation in and promotion and maintenance of relationships in the individual’s immediate and larger social network (e.g., neighborhood, town, society) are vital.

Types of Social Support Individuals in crisis may benefit from short-term crisis management or longer-term support for general life issues (e.g., adjusting to loss of a child or parent). Families often play key roles in providing all types of support, and extended resources aid in meeting those needs that the family cannot address. Types of social support include (House & Kahn, 1985):

r r r r

Instrumental support (e.g., offering direct assistance) Informational support (e.g., sharing information about the illness) Appraisal support (e.g., aiding in assessing the illness and/or decision-making) Emotional support (e.g., providing counseling)

Barriers to Seeking Social Support Though empirical literature repeatedly demonstrates the value of employing external sources of support, individuals and/or families especially from Anglo-Saxon communities may interpret such use as a marker of weakness and/or failure to independently cope with the stressor. Additionally, individuals may wish to utilize professional services but be unable to afford them (Walsh, 1998).

Case Conceptualization of Paul Now that we’ve examined the meanings behind adaptation and coping, the neurobiological correlates of fear and sadness, and the role of social support in handling medical adversity, let’s take another look at what we know thus far about Paul. His cognitive difficulties may have neurobiological underpinnings that may, in turn, relate to his silence. At this point, however, it is unclear to what extent his quiet


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presentation is reflective of his personality. He described his wife as a significant source of support, and it is possible that her absence during most of the visit related to Paul’s silent disposition. He also claimed to be comfortable with end-of-life issues but did not define “issues” or rate his comfort level on a meaningful scale.

Case Vignette 6.1.2 Continuation Paul returns to the hospital the following day to continue testing. He arrives again with his wife, who stays during today’s visit and anxiously asks several questions about the meaning behind these “cognitive difficulties.” Paul has been healthy for most of his life, with the exception of essential hypertension currently well controlled with diet and medication and osteoarthritis. He denies any personal history of a psychiatric illness and assures you with a chuckle that he’s not crazy and can hold it together just fine. He denies any definite problems with his sleep or appetite. Paul is again quiet and looks at the ground as his wife chastises him about being a difficult patient, says he is to blame for being sick, and lectures him about the necessity of taking better care of himself. You are in the room as they talk to their daughter and overhear Paul suddenly start screaming that she can be as cool and comfortable as she wants to be about his cognitive difficulties and can leave the entire family and never talk to him again if she chooses.

Adaptive and Maladaptive Methods of Adapting to and Coping with Medical Adversity Emotional, cognitive, and behavioral strategies of adaptively or maladaptively coping with medical adversity are person-, problem-, and situation-specific and can either develop within an individual or group or be drawn externally from social networks and the larger community. Having a pool of adaptive strategies from which to select is best in effectively coping with stressors. Several such strategies are summarized in Tables 6.3 and 6.4. (For a detailed review, see Friedman et al., 2003; McCubbin & McCubbin, 1993.)

Adapting to and Coping with Illness in the Context of the Family Families can also play a significant role as agents of social change during medical adversity (Burr et al., 1994; McCubbin & McCubbin, 1993; Walsh, 1998). The success of adaptation is determined by the family’s ability to function and adapt to change; the situational pile-up of demands, transitions, strains, and stressors; and family communication. Those families with affirming and/or stress-reducing communication (e.g., calm, soothing support) are more likely to adapt to stress compared

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Table 6.3 Adaptive methods of adapting to and coping with medical adversity Cognitive coping strategies Normalizing involves focusing thoughts, attention, and behaviors on the normal aspects of life and may be achieved through maintaining rituals and routines that preexisted the stressor, defining life as normal, participating in activities that reflect the normalcy of the individual and/or family, and minimizing attention to any negative social effects of the stressor (e.g., stigma) Cognitive reframing and passive appraisal describes adjusting the meaning of a situation and viewing stressors as something that will care for themselves Joint problem solving involves identifying and communicating in an effort to isolate, select, carry out, and monitor solutions based on shared input from everyone involved in the problem-solving process Becoming educated about medical adversity is an easy method for individuals to both increase the feeling of control in uncertain situations and better evaluate situations when making decisions. It offers medical teams a means of communication with patients and families and is associated with effective coping and decreased stress Effective communication Sharing ideas and feelings, being honest and clear, and using humor significantly effect coping during medical adversity

Table 6.4 Maladaptive methods of adapting to and coping with medical adversity Individual methods Denial is a defense mechanism that allows individuals to disbelieve that a situation or some aspect thereof exists Emotional distancing describes an inability to cultivate close, emotional relationships and may occur during periods of extreme stress Creation of myths involves suspension of reality by altering belief systems. Myths are produced when wishes and expectations have not been fulfilled and may serve as reflections of both inner and outer states of an individual Group methods Scapegoating involves a group negatively labeling, blaming, and displacing tensions, hostilities, guilt, and stress on one member while appearing to have achieved group harmony and cohesiveness Triangling gives the illusion of limiting and diminishing group tensions by welcoming additional members on whom the stress is displaced Threats involving permanent ostracism, self-destructive acts of other members of the group (e.g., suicide), and emotional withdrawal may be posited when one group member appears to display autonomy and independence from the group and the group fears losing cohesiveness Dissolution and Addiction: During periods of extreme stress, attempts to reduce tension may result in separation from loved ones (e.g., divorce), addiction (e.g., gambling, substance use), or violence

to families with conflict-escalating communication (e.g., yelling, blaming), which elevates tension (Friedman et al., 2003). Adaptive relational methods of coping with medical adversity are summarized in Table 6.5. (For a detailed review, see Walsh, 1998).


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Table 6.5 Adaptive relational methods of adapting to and coping with medical adversity Family group reliance involves increased structure and organization in the family and home (e.g., chores, visits, mealtimes) and more rigid time schedules and routines. It can lead to increased integration, cohesion, strength, and predictability, thereby leading to increased coping with the stressor Increased family cohesion may be achieved through involvement in shared leisure-time activities and rituals, especially when these rituals maintain and foster shared identity and world views among group members and increase integration, cohesion, morale, satisfaction, and resilience. Among families, cohesion is characterized by emotional bonding among family members and is considered to be a central attribute to the family unit Role flexibility describes the ability for family members to share and change roles during times of stress. It is essential for maintaining the equilibrium between stability and change and thereby increases adaptive coping with developmental, environmental, and life stressors

Case Conceptualization of Paul Now that we have discussed how the family can influence a patient’s ability to adaptively or maladaptively cope with and adapt to medical adversity, let’s take another look at Paul. We cannot yet be sure about the nature of his quiet disposition; however, but we know that he has been quiet both on his own and while being chastised by his wife, who appears anxious. We have also caught a glimpse of him screaming threats at his daughter, suggesting that his and his family’s methods of coping and adaptation are dysfunctional. He appears to have some stigma toward mental illness, suggesting that he may not be very receptive to acknowledging having difficulty coping with his current medical situation.

Case casevignette 6.1.3 Continuation Paul was cooperative and forthcoming during a semi-structured interview and mental status exam, which was remarkable for blunted affect and tearfulness . He denied any substance use, including coffee and cigarettes. Paul revealed having served in the Korean War and having grown up Black in the United States before the Civil Rights Movement. He indicated having a troubling relationship with each of his six children and admitted to being “too hard” on them and unnecessarily screaming at them too often. He denied having much of a support network outside of his family. Paul denied feeling suicidal and expressed his hopes to live as long as possible, reiterating feeling comfortable with the concept of death and attributing these feelings to his Christian faith and daily prayer.


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Factors Influencing Coping and Adaptation Sociocultural Values Important variables in understanding and considering adaptation and coping strategies are culture and society. A significant amount of research has demonstrated wide variation in the use of the strategies discussed in this chapter, and it is imperative that medical staff sensitively respond to the patient’s and family’s values and norms. For example, the extent to which individuals rely on internal and external coping and adaptation strategies varies across cultures, and medical staff are advised to take cultural values and background into account when assisting patients and their families in adjusting to illness (Friedman et al., 2003; Friedman & Ferguson-Marshalleck, 1996). Similarly, many individuals and families may find that spirituality and/or religious beliefs lie at the core of coping with and adapting to medical adversity. However, reliance on these beliefs varies across developmental, cultural, and socioeconomic groups (Clark & Heidenreich, 1995).

Gender Differences Methods of coping tend to vary across genders. Women use more strategies that involve closeness and intimacy, such as reaching out, sharing concerns with family members and friends, openly expressing emotions, cognitive reframing, delegating, and taking time for self-care; men, on the other hand, tend to withdraw more, keep emotions hidden, and use alcohol (Burr et al., 1994).

Development Special consideration and attention should be given to the effect of developmental stage on coping and adapting to medical illness and trauma. This is particularly true for children, whose experiences are especially influential in shaping future reactions to hospitals and medical procedures. Further discussion on the role of development in adjusting to various transitions is provided in Chap. 4, Learning Principles of Human Behavior.

Bio-psycho-social-cultural-spiritual Conceptualization Now that we have garnered information pertinent to most of our learning issues, let’s review the neurobiological, social, psychological, and spiritual information relating to Paul’s case conceptualization so that we can identify its impact on his psychiatric presentation:


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Biological Past: Genetics (no known history of psychiatric illness in patient or family), history of hypertension Presenting problem: Cognitive difficulties

Psychological Past Trauma (United States War Veteran; history as a racial minority in the United States before the Civil Rights Movement) Personality (stoic disposition) Present Affect (blunted; tearful; quiet/silent) End-of-life issues (eager to live as long as possible; comfortable with death; no suicidality) Possible stigma about mental health problems, including cognitive difficulties


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Married to wife whom he describes as supportive and who appears anxious Six children; troubled relationships; none live in same city; use of threats toward them No support network outside of family Scapegoating and blame from wife Christian/prays daily

As we conceptualize Paul’s case and consider effective interventions, it may be helpful to continue the inquiry process outlined in Table 6.1 and summarize the current hypotheses in a diagram (Fig. 6.1).

Psychosocial Interventions to Facilitate Adapting to and Coping with Medical Adversity Developing and practicing adaptive coping when facing medical crises can be challenging for many patients, especially when they are used to employing maladaptive coping strategies in their daily lives. As a result, psychotherapy for individuals and families is often recommended and has been empirically demonstrated to benefit patients struggling to cope with medical adversity.

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Biological


Hypertension Possible neurobiological Vulnerability (see table 6.2)

Stressor of condition

Wifeís anxiety Stigma

Cognitive deficits

Blunted affect, stoic Individual Psychotherapy

Scapegoating/blame

Family psychotherapy Sadness and anxiety Troubled relationship with children, Who are not in the city History of trauma?

Fig. 6.1 Bio-psycho-social-spiritual case conceptualization model of our sample client Paul. This model demonstrates the interrelated nature of biological, psychological, social, and spiritual variables relevant to case conceptualizations, as demonstrated through the case sample of Paul. Solid arrows represent mechanisms underlying clinical hypotheses; presenting symptoms are in boxes; potential therapeutic interventions are in ovals and linked with dotted arrows; and proximal etiological variables are underlined and asterisked

Additionally, several psychosocial models have been developed to guide medical staff in both addressing maladaptive coping and facilitating in the development of adaptive coping methods. Specific psychosocial strategies include: reviewing the event that led to the injury; processing the sensory experience of the event; assessing beliefs related to the event; and using desensitization, relaxation techniques, and pain management for medical interventions. Specific strategies for pediatric patients include using drawings and play to symbolize and elaborate the event further, explaining medical interventions carefully to the child, increasing the child’s sense of control over their own bodies, and assisting the parents to manage their own affect relating to the event and subsequent injury.

Case Conceptualization of Paul When we examine Paul’s story, though still incomplete, we can see the great extent to which biological, psychological, social, and spiritual factors interact and influence his presenting symptoms of cognitive deficits and quiet, blunted, and tearful affect. It remains unclear whether these symptoms reflect underlying depression and/or anxiety. However, because Paul’s personal history and family presentation reflect the use of some maladaptive methods of coping with his cognitive deficits (e.g., silence, screaming), it is possible that his daily life and family relations would improve from psychosocial interventions. Let’s take a look at a psychosocial assessment conducted 6 months following the end of a psychosocial intervention.


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Case Vignette 6.1.4 Conclusion Following a 3-month intervention of weekly family therapy and individual therapy focused on processing Paul’s experience with his cognitive deficits, reviewing previous and current family relations, and increasing family cohesion, reliance on one another, and role flexibility, Paul arrives for a 6-month follow-up assessment. His wife is accompanying him and stays during the entire appointment. Together, they indicate that the amount of screaming in their family has significantly decreased, while the amount of support and communication has increased. They both become tearful and link arms as they admit that they continue to struggle with Paul’s cognitive difficulties and unknown diagnosis and sometimes lash out at each other. Overall, though, they express gratitude for their therapy.

Conclusions As Paul’s case illustrates, adaptive coping with medical illness is influenced by many different factors, especially those related to biology, psychology, social support, and spiritual beliefs (e.g., the type and onset of the illness, individual and family coping styles). It is imperative to assess patients and, when possible, their family members not only on their medical illness but also on their adjustment to the illness.

Review Questions 1. Maladaptive methods of coping with and adapting to medical adversity include (a) (b) (c) (d)

Addiction Triangulating Threat All of the above

2. Adaptation involves (a) Specific behaviors aimed at preventing, avoiding, or controlling specific stressors (b) Changing external situations to improve internal responses (c) Use of internal and external resources, coping, and problem-solving strategies aimed at managing demands of stressors (d) Selection of only one effective strategy to adjust to stressors

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3. Which of the following is recognized as a specific type of support? (a) (b) (c) (d) (e)

Instrumental Informational Appraisal Emotional All of the above

4. Assessing beliefs related to medical trauma has been discussed as one method of (a) (b) (c) (d)

Maladaptive coping Facilitating adaptive coping Both of the above Neither of the above

Answers 1. d, 2. c, 3. e, 4. b

References Burr, W., Klein, S., Burr, R., Doxey, C., Harker, B., Holman, T., et al. (1994). Reexamining family stress: New theory and research. Thousand Oaks, CA: Sage. Carlson, N. (2006). Physiology of behavior (9th ed.). New York: Allyn & Bacon. Clark, C., & Heidenreich, T. (1995). Spiritual care for the critically ill. American Journal of Critical Care, 4(1), 77–81. Friedman, M. M., Bowden, V. R., & Jones, E. G. (2003). Family stress, coping, and adaptation. In M. M. Friedman, V. R. Bowden, & E. G. Jones (Eds.), Family nursing: Research, theory, and practice (5th ed.). Upper Saddle Ridge, NJ: Prentice Hall Health. Friedman, M. M., & Ferguson-Marshalleck, E. (1996). Sociocultural influences on family health. In S. Hanson & S. Boyd (Eds.), Family health care nursing: Theory, practice & research (pp. 81–98). Philadelphia: Davis. House, J. S., & Kahn, R. L. (1985). Measures and concepts of social support. In S. Cohen & S. L. Syme (Eds.), Social support and health (pp. 83–108). Orlando, FL: Academic Press. McCubbin, M. A., & McCubbin, H. I. (1993). Families coping with illness: The resiliency model of family stress, adjustment and adaptation. In C. Danielson, B. Hamel-Bissell, & P. Winstead-Fry (Eds.), Families, health, and illness: Perspectives on coping and intervention (pp. 21–63). St. Louis: Harcourt Health Services. Walsh, F. (1998). Strengthening family resilience. New York: The Guilford Press.

Chapter 7

Violence and Abuse Jeanelle J. Sugimoto and Anthony P.S. Guerrero

This chapter reviews conditions that are among the leading causes of morbidity and mortality throughout the life cycle, yet remain under-recognized and underaddressed in clinical practice. At the end of this chapter, the reader will be able to 1. Discuss typical presenting signs and symptoms of patients who are victims of various types of violence or abuse 2. Define the different types of violence and abuse 3. Discuss resources and treatments for victims of violence and abuse

Case 7.1.1 Presenting Situation: Mary Infante Mary Infante is a 32-year-old married woman who is 20 weeks pregnant and having severe cramps. She has had two miscarriages in the past and is worried that she may be having another one. Previous laboratory tests were remarkable. Upon physical examination, she has bruising on the upper arms and abdomen. The bruising is not noticeable on any areas of the body that are not covered by her clothing. Ms. Infante is a secretary at a local law firm. Her husband was recently laid off from his position with a construction company and is seeking another company to work with. He has apparently been let go from a number of positions since they have been together. They have been married for approximately 3 years, but have not yet been able to have children. A psychiatric consultation was requested by her physician to evaluate the situation.


J.J. Sugimoto Program Manager, Asian/Pacific Islander Youth Violence Prevention Center, Department of Psychiatry, University of Hawai‘i John A. Burns School of Medicine A. Guerrero, M. Piasecki (eds.), Problem-Based Behavioral Science and Psychiatry, C Springer Science+Business Media, LLC 2008

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Abuse and Neglect of Adults Although further information must still be gathered from the patient and her husband, spousal abuse should be a strong consideration in this case. All physicians in all specialties must be aware of the physical and emotional signs of violence and abuse. As can be seen in this case study, the obstetrician discovered the symptoms in the context of a recent miscarriage. Injuries and bruising can be discovered during any physical examination, and key statements that may reveal underlying problems can be elicited during any patient interview. It is up to the physician to make the initial identification and refer the patient to an appropriate specialist. Family violence is a general term that includes acts of violence between family members or other individuals with close relations (Director & Linden, 2004). Domestic violence is a specific type of family violence, and includes acts between intimate partners (therefore the term is also interchangeable with “intimate partner violence”) (Director & Linden, 2004). It includes acts that may coerce, control, or demean the victim (Director & Linden, 2004). The American College of Emergency Physicians outlines domestic violence as “. . . part of a pattern of coercive behavior which an individual uses to establish and maintain power and control over another with whom he or she has or had an intimate, romantic, or spousal relationship. Behaviors include actual or threatened physical or sexual abuse, psychological abuse, social isolation, deprivation, or intimidation” (American College of Emergency Physicians, 1995). The DSM-IV-TR notates abuse and neglect under “Other Conditions that May be a Focus of Clinical Attention” and categorizes these diagnoses as follows: (1) physical abuse of child, (2) sexual abuse of child, (3) neglect of child, (4) physical abuse of adult, and (5) sexual abuse of adult. According to the July 2000 National Violence Against Women Survey, 7.7 % of women surveyed reported having experienced rape from an intimate partner at some point in their life. Twenty-two percent reported having been physically assaulted, 4.8 % reported having been stalked, and 25.5 % reported having been victimized in some other way, all by an intimate partner (Tjaden & Thoennes, 2000). The effects of domestic violence are varied and widespread. Not only do the victims suffer physically and emotionally, but family and friends become involved. The situation is especially taxing on children who may witness the abuse. These secondary victims may in turn show their own signs and symptoms, including behavior changes, sleep disturbances, and increased aggression (Director & Linden, 2004). They may also be at risk for posttraumatic stress disorder, acute stress disorder, adjustment disorder, and other conditions (please refer to Chaps. 23 and 30).

Case 7.1.2 Continuation You interview Ms. Infante individually. You talk to her about her career. She received a merit-based raise, and her co-workers even put together a small dinner to thank her for such good work. When asked about her husband’s career, she comments

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that he was recently laid off from his job. Apparently, the construction company he worked for was restructured. She thinks he feels cheated out of a position, and even wrote an angry letter to the president of the company. After further inquiry, she reveals that the miscarriages might have been caused by spousal abuse while she was pregnant. You suspect that her husband also abuses her when she is not pregnant. She says that he is a very caring husband when in the presence of others, but his temper “gets the best of him” when they are alone. He relates his temper to the severe physical and emotional abuse he had experienced while growing up. You then call the husband into the room to discuss your concerns with the current pregnancy. Overall, he is cordial and polite and seems attentive to his wife. You note that he often interrupts his wife while she is attempting to answer a question. You politely ask him to refrain from answering questions directed at his wife, but he continues to answer questions for her.

Please proceed with the problem-based approach! While there are no definitive tests that can determine with 100 % accuracy that an individual is a victim of domestic violence, there are certain risk factors and signs/symptoms the physician can consider (Director & Linden, 2004).

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Risk factors – Being female – Being younger – Being single, separated, or divorced Physical signs and symptoms – Initial signs may be vague and nonspecific – Injuries

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Injuries that are not consistent with the patient history or complaints that are not consistent with the problem Recurrent injuries with increasing severity over time Multiple injuries in different stages of healing Injuries to central body areas (breasts, abdomen, chest) in addition to the face and extremities Injuries to normally protected areas (inner thigh, inner arm) Injuries suggesting defensive posture

– General health concerns

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Higher rates of general health problems (headache, back pain, vaginal infections, gastrointestinal complaints)

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Frequent exacerbations of chronic illnesses (asthma, diabetes, hypertension) Increased use of the health care system, but delay in seeking treatment for the actual problem Lack of prenatal care Injury during pregnancy

Emotional signs and symptoms – Frequent reporting of emotional symptoms (depression, low self-esteem, increased daily stressors, anxiety) – Feelings of guilt and isolation – Possible substance abuse, eating disorders, posttraumatic stress disorder – Possible suicidality

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Characteristics of the abuser – – – – – – – –

Substance abuse Lower educational achievement Intermittent employment Victimization as a child Feelings of inadequacy Personality disorders (antisocial, borderline) Younger Hovering, domineering presence in spite of cordial/attentive appearance to outside parties – Verbal abusiveness The physician’s first step toward treatment is screening. The screening process not only pushes all parties toward the end goal but also lets the patient know that the physician is concerned for his/her welfare and safety. The patient should be interviewed alone and in a supportive, nonjudgmental, confidential setting (Director & Linden, 2004). There are a number of protocols available to physicians. Overall, most of the literature suggests using simple, open-ended questions. Below are some suggested questions, ranging from less to more invasive.

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Simple and open-ended (Director & Linden, 2004) – How does your partner treat you? – Are you or have you been in a relationship in which you felt you were treated badly? – We all fight at home; what happens when you and your partner fight or disagree? – Do you ever feel afraid of your partner? – Has your partner ever prevented you from leaving the house, seeing friends, getting a job, or continuing your education? – Has your partner ever destroyed things you care about?


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More direct questions – The Partner Violence Screen—65–71 % sensitivity (Feldhaus et al., 1997)

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Have you been hit, kicked, punched, or otherwise hurt by someone within the past year? If so, by whom? Do you feel safe in your current relationship? Is there a partner from a previous relationship who is making you feel unsafe now?

– The “StaT” Screening Tool—97 % sensitivity (Liebschutz & Paranjape, 2003)

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Have you ever been in a relationship in which your partner has pushed or slapped you? Have you ever been in a relationship in which your partner threatened you with violence? Have you ever been in a relationship in which your partner has thrown, broken, or punched things?

Case Vignette 7.1.3 Conclusion You decide to admit Ms. Infante for threatened miscarriage and for further assessment and intervention for domestic violence. You consult a social worker, who meets with her individually and provides her with information on spousal abuse and women’s shelters. A safety plan is formulated that includes cash, a cell phone, and keeping the car tank full of gas. You involve Ms. Infante’s sister, as well as two of her closest friends. She will stay in the hospital for a few days, and then with her sister. The social worker also assists Ms. Infante with a referral to legal counsel, in case she wishes to file a formal restraining order against the husband. You and the social worker meet with her and her sister about a month later. She states that she and her husband will attempt marriage counseling with a psychologist the social worker recommended. During this period however, she will still stay with her sister to maintain her personal safety. After the initial screening, there are some general steps that should be taken to help abuse victims (McLeer & Anwar, 1987):

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Obtain history Diagnose and treat injuries Evaluate the emotional safety of the patient Determine the risk to the victim Determine the need for legal intervention Develop a follow-up plan Document findings

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Brown (1997) applied the Trans-theoretic Model of Change to the process of a victim’s emergence from the cycle of violence. This model is discussed in Chaps. 4 and 10. There are many reasons why victims are unable to break out of the cycle of violence. If the physician has a good understanding of the victim’s reasoning, he or she is more likely to make an appropriate referral. Below are some common scenarios.

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Common reasons for the victim staying in an abusive relationship: – – – –

Common physician-related reasons why the victim may not disclose information to the physician – – – – – – –

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Nonrecognition that he or she is being abused Fear of the abuser, or fear of retaliation Desire to fulfill predetermined cultural or gender roles Fear of losing financial or childcare support

Failure of the physician to inquire Discomfort with talking to patients about this topic Lack of confidence in ability to diagnose abuse Perceived inability to offer appropriate referrals if diagnosed Fear of offending the victim or crossing a cultural barrier Lack of time or privacy with the individual Personal experiences with abuse

Common patient-related reasons why the victim may not disclose information to the physician – – – – –

Low self-esteem Lack of trust toward the physician Fear that disclosure will involve the police or child protective services Fear of being judged Language or cultural barriers

The Community Coalition on Family Violence (CCFV) notes that five statements can provide important encouragement to an abuse victim (Williams, 2005):

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You’re not alone. No one has the right to hit you. Domestic violence is not your fault. It’s against the law. Help is available and I’ll be here when you need me.

Physicians should also be aware of other specific types of abuse among adults, including rape or sexual assault, and elder abuse. There are several misconceptions about rape, including that it involves a sex-deprived young male attacking an attractive female, that it is not a violent crime, and that it is a street crime (rather than one that may even occur between partners and spouses). According to Englander (2007), there are various types of perpetrators,


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including violent rapists (who may engage in brutal beatings, who view sex as secondary, and who are chronically angry) and power rapists (who typically use only enough force to complete the act and who have underlying feelings of inadequacy). In general, perpetrators of rape often demonstrate a lack of empathy and an acceptance of cognitive misperceptions (e.g., that the victim deserved it or is making too big a fuss about it). Alcohol or substance abuse (on either the part of the perpetrator or victim) can be a risk factor (though by no means an excuse) for rape to occur. Elder abuse can include physical abuse (including over-medicating, undermedicating, force-feeding, inappropriately using physical restraints, and exposing to the elements) and emotional abuse (including treatment like a child and isolation from family and friends, neglect, sexual abuse, and financial abuse) (Muehlbauer & Crane, 2006). Given the unfortunately high prevalence of victimization and the potential serious sequelae, it is critical for physicians of all specialties to screen all patients of all ages for abuse. The next section is focused on abuse and neglect of children.

Case Vignette 7.2.1 Nicholas Head An emergency room physician refers Nicholas Head, a 5-year-old boy, to your care. Nick’s mother reported that he was running in the house and tripped and hit his head on the corner of their dining room table. Upon examination it was clear that Nick’s left eye and the left side of his face are badly bruised. During the complete full-body examination, the ER doctor saw bruising on his upper arm and tenderness when palpating his abdomen. He orders several X-rays, one of which indicates that the boy has a healing fractured humerus. His mother reports that he was roughhousing on the playground with some other children at school and fell off the jungle gym. You are called to join the case to perform a psychiatric consultation on the child.


Abuse and Neglect of Children At this point, child neglect and/or abuse is a valid suspicion. Child abuse is one of the leading causes of injury-related mortality in infants and children (McDonald, 2007). According to the Centers for Disease Control and Prevention, among all children confirmed by child protective service agencies in 2002 as being maltreated, 61 % experienced neglect, 19 % were physically abused, 10 % were sexually abused and 5 % were emotionally or psychologically abused (www.cdc.gov). In 2002, an estimated 1,500 children died from maltreatment, 36 % from neglect, 28 % from physical abuse, and 29 % from multiple maltreatment types (www.cdc.gov).

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The Child Abuse Prevention and Treatment Act (CAPTA) defines abuse as “. . . a recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm; involves a child; and is carried out by a parent or caregiver who is responsible for the child’s welfare (McDonald, 2007).” Child abuse can be categorized as neglect, emotional abuse, physical abuse, and sexual abuse, and each of these can be further categorized according to the definitions below (McDonald, 2007). Child neglect

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Physical neglect—basic needs for food, clothing, shelter, hygiene, protection, supervision not met Emotional neglect—lack of love and affection Educational neglect—failure to enroll child in school Medical neglect—failure to seek medical assistance to upkeep child’s well-being Emotional abuse Several subtypes, including rejection, isolation, terrorism, ignorance, psychological unavailability, corruption, and inappropriate expectations of or demands on the child. Physical abuse, of which typical findings may include Bruises, including – Handprints (typically adult-sized) – Unusually distributed lesions – Lesions at various stages of healing Bites (also, typically adult-sized) Burns – Cigarette burns – Burns with clear demarcation and uniform depth (e.g., submersion burns) Fractures – Posterior rib fractures – Long bone fractures in children under 2 years of age – Scapular, spinous process, sternal fractures Abdominal trauma Head trauma – Retinal hemorrhages Trauma that is inconsistent with the reported mechanism of injury Sexual abuse The Child Abuse Prevention and Treatment Act (CAPTA) defines sexual abuse as “The employment, use, persuasion, inducement, enticement, or coercion of any


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child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children (McDonald, 2007).” Children who experience any of these types of abuse may demonstrate emotional symptoms, which include social withdrawal, anger or aggression, feeding disorders, developmental delay, or emotional disturbances. A number of risk factors for child abuse and neglect have been identified. They can be categorized by caregiver, child, and family/environmental factors (McDonald, 2007).

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Caregiver factors – – – – – –

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Child factors – – – – –

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Criminal history Inappropriate expectations of the child Mental health history Misconceptions about child care Misperceptions about child development Substance abuse

Behavior problems Medical fragility Nonbiologic relationship to the caretaker Prematurity Special needs

Family and environmental factors – – – – –

High local unemployment rates Intimate partner violence in the home Poverty Social isolation Lack of social support

Abusive parents or caregivers may demonstrate the following characteristics (Lau, Valeri, McCarty and Weisz, 2006; McDonald, 2007):

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They may exaggerate the child’s behavior, or even put blame on the child for the family’s problems. They have low tolerance of behaviors that would otherwise not be seen as serious. They will make few statements or gestures that positively support the child. They are more likely to be critical in interactions with the child. They possess overall negative impressions of their child and the child’s behavior. They may describe their child as bad, burdensome, or even “evil.”

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They do not explain the child’s injuries. The history changes over time or history of self-inflicted trauma does not correlate with development.

Case Vignette 7.2.2 Continuation You and a hospital social worker interview Nick and his mother. Currently they live in a low-income housing complex. Nick’s father is not around, and likely left the city before the boy was born. Therefore, the mother is forced to work two jobs to make ends meet. While she is at her second job in the evenings, the mother’s live-in boyfriend watches over her son. You question the mother about Nick’s living conditions at home. She states that Nick receives the three meals a day that he deserves and has a roof over his head. When asked how many hours of the day she spends with her son, she becomes defensive and goes on about her two jobs and how little sleep she gets each night. When questioned about the incident that produced Nick’s black eye, she alleges that she was not home at the time of the accident. You manage to question Nick independently of his mother. When asked about his home he says that he usually goes to school without eating breakfast and is lucky to have dinner at night. On certain nights, his mother’s boyfriend will order pizza or purchase fast food from the convenience store around the corner from their house and give him a portion. On other nights, however, the boyfriend is not around, and so Nick is forced to fend for himself. On certain mornings, he will see his mother getting ready for work and inquire if any breakfast is available. When probed on what her response is, he looks down at the floor and states that occasionally his mother will become angry at his question so recently he has stopped asking. Nick won’t answer any more questions about the boyfriend.

Please proceed with the problem-based approach! Because of the apparent neglect and abuse, the assessment of this child requires both medical and legal investigation. Assessment must include history of the alleged abuse, assault, or neglect; a medical history; a psychosocial history (including family composition, substance use in the home, and previous involvement with Child Protective Services); a review of systems; a comprehensive physical exam (including an anogenital exam if sexual abuse is possible); and a collection of forensic evidence and forensic interviews (Laraque, DeMattia, & Low, 2006). Especially in sexual abuse cases, examinations should be done by a health care professional trained in forensic examination techniques. Documentation is crucial during all assessments (interviews and physical assessments). Comprehensive evaluation is


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time-consuming, but statistics show that 50 % of abused children will likely be abused again (McDonald, 2007). The following are general guidelines for interviewing and examining youth who are possible victims of abuse or neglect (Laraque, DeMattia, & Low, 2006; McDonald, 2007).

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Setting the tone – – – – – – –

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Initiate general rapport-building Explain who you are and why you are there Ask if the child knows why he/she is there Clearly state that confidentiality will be upheld Explain any physical exams you will conduct Allow child to handle any equipment you will be using Obtain consent for each part of the exam, and for the presence of anyone else who will be allowed in the room during the exam (it must be explained to parents/caregivers if the child requests that they not be in the room) – Establish ground rules prior to commencing the exam (stop at anytime, etc.) Type of environment – The examination should be in a safe, neutral place if possible – Only one interviewer should be present; multiple adults and multiple interviews are discouraged – If possible, interview the child separately from the parents/caregivers – Offer the option of writing answers down or making a sketch When speaking – Use short and simple sentences, concrete terms, proper names, direct questions – Do not be biased, leading, presumptive – Determine the child’s language and development – Verify the child’s statements; rephrase questions if needed; ask if the child understands the question

The evaluation process should not further traumatize the child. In certain instances, it may be helpful for a nonoffending parent (usually the mother if she is not suspected in the abuse) to be present for the exam (Laraque, DeMattia, & Low, 2006). Below are the recommended exams and assessments that should be done even in the middle of a hectic emergency room. While each case will be different and have several contributing factors, failure to conduct an exam properly can in the end devastate a criminal case and cause lifelong trauma for the child.

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Photography of all injuries (preferably taken by a forensic investigator or medical photographer) – Obtain informed consent if possible, although it is not required in child maltreatment cases

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– – – – – –

Use a color or digital camera, with the highest resolution possible Photograph injuries before treatment Photograph from different angles and take at least two photos of each injury Use a ruler or coin to give perspective of the injury’s size Include the patient’s face in at least one photograph Document the patient’s name, location of injury, date, photographer, names of those present on the back of the photo – Place photos in a sealed envelope, mark as confidential, and attach to the medical record. Maintain chain of custody

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Guidelines for further assessment in cases of suspected sexual abuse: General principles – Should be done by a medical professional trained in forensic examinations. – Should be done promptly if child complains of dysuria, anal or vaginal bleeding, vaginal discharge, or pain with defecation; or if alleged incident occurred less than 72 hours prior to presentation. – If alleged incident occurred more than 72 hours prior to presentation, child can be scheduled for an examination at a center specializing in sexual assault examinations. – Most sexual abuse cases do not show findings upon physical examination unless the child is examined within 24 hours of the incident; therefore, obtaining a history is especially critical. Examination should include collection of – Victim clothing, debris, stains on skin (dried secretions), oral swabs and smears, vaginal/penile swabs and smears, rectal swabs and smears, pubic hair brushings/combings, head hair combings, genital swab, saliva and blood specimen, reference head and pubic hair, fingernail scrapings or clippings, and nasal mucous – Condoms, tampons – Tests for sexually transmitted diseases – Linens and other clothing

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Guidelines for further diagnostic studies: Recommended in most cases – Ophthalmologic studies—dilated, indirect ophthalmoscopy performed by an ophthalmologist to detect retinal hemorrhages in children younger than 2 years – Radiological studies—head CT to detect subarachnoid, subdural, or intraparenchymal injury; skeletal survey radiography (e.g., of the spine, extremities, skull)—suspected old or new fracture – Laboratory studies—evaluation of amylase, complete blood count, hepatic transaminases, lipase, partial thromboplastin time, prothrombin time, fecal occult blood test, urinalysis, urine toxicology—to detect genitourinary or abdominal trauma and to ensure no underlying blood disorder


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Optional – Abdominal CT—if history, examination, or laboratory results suggest abdominal trauma – Bone scan—to find occult fractures up to 2 weeks after injury – Dental consultation—if there is a bite present, dentists can determine the source – Magnetic resonance imaging of the head—if CT of the head is inconclusive

Case Vignette 7.2.3 Conclusion The social worker calls CPS and expects a return call. You admit Nick to the hospital pediatrics unit for his safety and to ensure that his immediate medical needs are addressed first, such as possible malnutrition. You learn later from an “auntie” that Nick has been more disruptive and aggressive in school. You hope that the boy, a victim of violence, does not go on to become a perpetrator of violence as an older child or adolescent. You wonder what interventions could prevent such an outcome. Of course the next step is arranging for involvement of a social worker who makes plans with CPS for a safe discharge. The following are some online resources about child abuse that may be helpful to the physician.

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Recognition and management – Visual Diagnosis of Child Abuse (available through http://www.aap.org) – Tennyson Center for Children (http://www.childabuse.org) – Child Abuse Evaluation and Treatment for Medical Providers (http://www. ChildAbuseMD.com) – MedlinePlus: Child Sexual Abuse (http://www.nlm.nih.gov/medlineplus/ childsexualabuse.html) – Child Welfare Information Gateway (http://www.childwelfare.gov)

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Crisis counseling – Childhelp USA (http://childhelpusa.org)

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State statutes – Child Welfare Information Gateway systemwide/laws policies/search/index.cfm)

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(http://www.childwelfare.gov/

Protocols and forms – California Governor’s Office of Emergency Services, OES 900 Forms (http://www.oes.ca.gov/Operational/OeSHome.nsf/CJPD Documents? OpenForm)

In this age of seemingly increased interpersonal youth violence being reported in the media, some consideration must be given to this topic. The literature shows an

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increased number of youth perpetrators. Therefore, assessment techniques must also adapt to this type of evaluation. The following are statistics from the 2006 Juvenile Offenders and Victims National Report:

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More than one-third of juvenile victims of violent crime known to law enforcement are under age 12. In 2002, 1 in 12 murders in the USA involved a juvenile offender. One-third of murders committed by a juvenile offender also involved an adult offender. On a typical day in 2004, about 7,000 persons younger than 18 were inmates in adult jails. Nearly 9 of 10 were being held as adults. Law enforcement agencies made 2.2 million arrests of persons under 18 years in 2003. The most serious charge in almost half of all juvenile arrests in 2003 was larceny-theft, simple assault, a drug abuse violation, disorderly conduct, or a liquor law violation.

The following are recommended priorities from the Commission for the Prevention of Youth Violence [2000]: 1. Support the development of healthy families. 2. Promote healthy communities. 3. Enhance services for early identification and intervention for children, youth, and families at risk for or involved in violence. 4. Increase access to health and mental health care services. 5. Reduce access to and risk from firearms for children and youth. 6. Reduce exposure to media violence. 7. Ensure national support and advocacy for solutions to violence through research, public policy, legislation, and funding. Hopefully, with care for this patient’s physical and emotional well-being and careful implementation of the above guidelines, this patient will not become one of the above statistics and will not suffer the same fate of the perpetrator in the first case vignette.

Review Questions 1. In the first case vignette, what signs were identifiable in both the wife and husband that would cause suspicion of spousal abuse? 2. Which of the following physical findings would raise the highest degree of suspicion for child abuse or neglect? (a) Retinal hemorrhages in a 2-year-old with head trauma, reportedly from falling out of bed (b) Second-degree burns in the shape of a splash mark on the leg of a 9-year-old, who reportedly spilled hot soup on himself (c) A fractured forearm in a 10-year-old girl who fell on outstretched hands while playing on the jungle gym


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(d) “Picky eating” and being below the fifth percentile for height and weight in a 3-year-old child (e) A child-sized bite mark on the shoulder of a 5-year-old who claims that the wound was inflicted by the 4-year-old sister during an episode of roughhousing 3. Which of the following are recommended strategies to prevent violent behavior in youth: (a) (b) (c) (d) (e)

Increase access to health and mental health care services Reduce access to and risk from firearms for children and youth Reduce exposure to media violence All of the above a and c only

Answers 2. a, 3. d

Bibliography American College of Emergency Physicians (1995). Emergency medicine and domestic violence. Annals of Emergency Medicine, 25, 442–443. Brown, J. (1997). Working toward freedom from violence: The process of change in battered women. Violence Against Women, 3, 5–26. Commission for the Prevention of Youth Violence. (December 2000). Youth and violence: medicine, nursing, and public health: Connecting the dots to prevent violence. http://www.amaassn.org/ama/upload/mm/386/fullreport.pdf. Accessed September 19, 2007. Director, T. D., & Linden, J. A. (2004). Domestic violence: An approach to identification and intervention.Emergency Medical Clinical of North America, 22, 1117–1132. Englander, E. (2007). Understanding Violence. Mahwah: Lawrence Erlbaum Associates. Feldhaus, K., Kozoi-McLain, J., Amsbury, H., Norton, I., Lowenstein, S., & Abbott, J. (1997). Accuracy of 3 brief screening questions for detecting partner violence in the emergency department. Journal of the American Medical Association, 277, 1357–1361. Laraque, D., DeMattia, A. & Low, C. (2006). Forensic child abuse evaluation: A review. The Mount Sinai Journal of Medicine, 72(8), 1138–1147. Lau, A. S., Valeri, S. M., McCarty, C. A., & Weisz, J. R. (2006). Abuse parents’ reports of child behavior problems: Relationship to observed parent–child interactions. Child Abuse & Neglect, 30, 639–655. Liebschutz, J., & Paranjape, A. (2003). How can a clinician identify violence in a woman’s life? In J. Liebschutz, S. Frayne, & G. Saxe (Eds.), Violence against women: A physician’s guide to identification and management (pp. 39–69). Philadelphia: American College of Physicians— American Society of Internal Medicine.. McDonald, K. C. (2007). Child abuse: Approach and management. American Family Physician, 75(2), 221–228. McLeer, S., & Anwar, R. (1987). The role of the emergency physician in the prevention of domestic violence. Annals of Emergency Medicine, 16, 1155–1161.

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Muehlbauer, M., & Crane, P. (2006). Elder abuse and neglect. Journal of Psychosocial Nursing, 44(11), 43–48. Snyder, H., & Sickmund, M. (2006). Juvenile Offenders and Victims: 2006 National Report. Retrieved April 19, 2007, from http://ojjdp.ncjrs.org/ojstatbb/nr2006/index.html Tjaden, P., & Thoennes, N. (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey, July 2000. Williams, B. (2005). Domestic violence: Medicine’s response. Tennessee Medicine, 98(10), 477–480.

Part III

Healthcare Principles

Chapter 8

The Physician–Patient Relationship My Kha and Melissa Piasecki

Among the many skills every student must learn in medical school, communication skills are far and away the most important. Effective communication helps with diagnosis and allows for solid physician–patient relationships. When patients feel their doctors understand and are honest with them, they are more likely to adhere to treatment. There is also some evidence that malpractice risk can be lessened with good communication skills. In this chapter, the problem-solving table columns have questions that specifically address the physician–patient relationship. At the end of this chapter, the reader will be able to 1. Discuss some of the factors that influence patient behavior 2. Describe the impact of physician–patient relationship on malpractice risk and its outcome 3. Determine specific factors affecting alliance 4. Identify the role of apology in medicine 5. Describe a model for the communication of bad news

Case Vignette 8.1.1 Miriam Phillips Mrs. Phillips is a widowed, overweight woman in her late 70s. She has been suffering from abdominal pain for several days prior to her same-day appointment. You are a few months out of residency working for an HMO. Your administrator recently acknowledged your excellent work but asked that you speed up the rate of patients seen and order less unnecessary tests as you are generating more costs than expected. First outpatient clinic visit: Mrs. Phillips had a 10:30-AM appointment. It has been a busy morning and as usual you are running behind.

M. Kha Resident in Psychiatry, University of Nevada School of Medicine


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You call out to the waiting room: Mrs. Phillips?! You’re already turning away as you see an elderly, slightly overweight and smartly dressed lady slowly get out of her seat. You glance quickly at her chart and note that she has a history of NIDDM, her temperature is 38.5 ◦ C and her pulse is 98. With brief eye contact, you introduce yourself, “I’m Dr. Smith and I’ll be taking care of you today.” You lead the way to the examination room. She settles in her seat, anxiously looking around the room. You stand, leaning against the sink and continue to read her chart as you introduce yourself. “What can I do for you today?” Mrs. Phillips: Well doctor, I know you’re very busy and I don’t want to take up too much of your time. I don’t know where to start, doctor. I guess I have been feeling this pain in my belly (pointing to her RUQ) and my son finally made me come in. Have you had this pain before? Mrs. Phillips: Well, no, but . . . (Interrupting.) What is the quality of the pain? Mrs. Phillips: Quality? Why I don’t know, it sort of comes and goes. I’ve been so sick to my stomach . . .. Is it associated with meals? Does it occur more after eating fatty foods? How long does it last? Mrs. Phillips: I’m sorry doctor, you’re going too fast (she is visibly flustered). I’ve never been too good at this medical talk. Sometimes the pain is worse after breakfast . . .. You continue writing in the chart as Mrs. Phillips talks. When did the pain start? As the interview progresses, you learn that Mrs. Phillips has abdominal pain in her RUQ, an associated abdominal tenderness, nausea and vomiting, and a positive Murphy’s sign on physical exam. You appear to have signs consistent with acute cholecystitis. You’ll need to get some labs and an ultrasound done for the diagnosis. You circle orders for a WBC, HbA1C, serum bilirubin, serum amylase, LFTs, and an abdominal ultrasound on a lab sheet, and hand this to Mrs. Phillips while saying, I think this will take care of things today. We’ll call you if the tests return abnormal. You can check out with the assistant at the front. Mrs. Phillips appears even more anxious. What is cholecystitis? It’s an inflammation of your gallbladder. Many people get it. Why don’t we get the results of the tests and then discuss it further. Mrs. Phillips: Well, okay doctor, you know best. Thank you for your time.


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Case Vignette 8.1.2 Continuation Mrs. Phillips gets the labs drawn but could not get the abdominal ultrasound scheduled until the following week. During the week, she developed worsening fever and chills. However, she did not know to call your office with these symptoms. You call her to come in when you receive her lab results showing a WBC of >15,000/µl. Telephone call: Mrs. Phillips, we just received your lab results and they are concerning. You need to come to the hospital right away as a direct admit. Mrs. Phillips: What’s wrong? Am I going to die? I’ve seen hundreds of patients with your condition. You will be fine. I will see you in the hospital. Mrs. Phillips goes to the hospital and finds that she has a temperature of 40 ◦ C. She appears toxic with shaking chills. An abdominal plain film was ordered and results were consistent with suppurative cholecystitis. She starts intravenous antibiotics and is scheduled for surgery. You enter the hospital room, flipping through the medical chart. Mrs. Phillips, you have a condition called suppurative cholecystitis. I have ordered some antibiotics and we scheduled you for emergency surgery. Your surgeon will be by to discuss the procedure further with you. Mrs. Phillips: How did this happen? I thought you said that my condition is not serious. She starts to cry. I know you’re busy, doctor, and you know what’s best but my son had some questions for you. He’s in the cafeteria right now. Will you come by later? He can wait until you’re free. Unfortunately, sometimes people with an inflammation of the gallbladder develop an associated infection. Once you get the antibiotics and surgery, you should be as good as normal. Your surgeon can give you and your son more specifics. I will be back to check on you after your surgery. During Mrs. Phillips surgery, she developed a cardiac arrhythmia that did not respond to emergency treatment and she did not survive. The surgeon communicates this news to her son.


Case Vignette 8.1.3 Conclusion You get a call from the Risk Management office of the hospital advising you that this case is under review and though you may express your condolences to the family, you may not discuss any of the details of the case or admit wrongdoing by apologizing

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for her death. Her son attempts to contact you in the following weeks asking you to return his calls. Though you fully intend to call him, your long days and uncertainty about how to proceed keep you from making the call. A month after Mrs. Phillip’s death, you receive a notification of a malpractice lawsuit from her son. It alleges malpractice resulting in wrongful death.

Case Vignette 8.2.1 Jared You have recently completed a residency in pediatrics and a fellowship in pediatric hematology–oncology. You are consulted at Children’s Hospital on an 8-month-old infant (Jared) with a rapidly enlarging abdominal mass. He initially presented to his pediatrician with irritability, vomiting, and failure to thrive. You review the chart, imaging studies, and laboratory results and speak with the referring physician about the infant prior to meeting with the infant’s parents for the first time in the hospital. You enter Jared’s room to see a young mother comforting the infant while the father sits anxiously on a chair by the mother’s side. They both look up as you enter the room; a mix of fear and hope fill their eyes. Mr. and Mrs. Nguyen? Mr. Nguyen: Yes. Are you the cancer doctor? Yes. You approach the Nguyens as you pull up a chair and reach out to shake both their hands in turn. My name is Dr. Smith. Jared’s doctor asked me to help in his care. I understand that this is a very difficult time for your family and I want you to know that I will try to answer your questions and be as honest with you as I can. You then settle back in the chair and continue. Why don’t we start with what your current understanding of Jared’s illness is? Mrs. Nguyen: There is something in his liver. They think it might be cancer. Can you take the cancer out? You sit with the Nguyens, educating them on the differential diagnosis and the steps that will be taken in the evaluation of this hepatic mass. You reassure them that the medical problem is completely unrelated to their parenting. The parents listen intently. You examine Jared carefully and point out and educate his parent’s on the physical exam findings as well as the imaging results. You answer the Nguyens’ questions and leave them with the direct office number where you could be reached.

Case Vignette 8.2.2 Continued After a full workup, Jared was diagnosed with hepatoblastoma. You discuss the options, including the risks and benefits of surgery, chemotherapy, and other alternative treatments. The parents consent to surgical treatment, but the initial attempt at a complete resection was unsuccessful because the tumor was too large. You meet with the parents after the surgery and explain that it is now necessary to start Jared on a chemotherapy regimen designed to shrink the tumor and make it resectable.


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You warn the parents of the risks of these agents. Though concerned and fatigued, they express confidence in your recommendations and decide to proceed. The appropriate chemotherapy protocol was ordered. Your pager goes off on the morning of Jared’s first round of chemotherapy and Jared’s nurse notifies you that Jared has a fever and just had a seizure. You ask the nurse to stop the chemotherapy, and you rush to the infusion room. There, an irritable and uncomfortable looking infant awaits you. However, it appears that Jared has stabilized. Looking through the notes, labs, and orders, nothing appears amiss. However, on closer examination, you note that the chemotherapy agent’s dose was calculated based on a weight of 9.3 kg. Someone had misread your 6.3 kg for 9.3 kg! After rechecking the calculations and confirming that the incorrect dose was infused, you ask the Nguyens to step into a private room. The Nguyens appear frightened. You ask them to sit and pull up a chair up to them. Jared appears to be doing okay right now. He just had a seizure and developed a fever after the chemotherapy was started. Mrs. Nguyen: What happened? Why did he have the seizure? Will he be okay? It appears that Jared was given the wrong dose of medicine . . .. Mr. Nguyen: What?! How could he be given the wrong dose? Who made the mistake? I know you are both upset and you have a right to be. I am so sorry that this happened. I don’t know where the mistake was made. However, I assure you I will personally investigate this and keep you informed on what the results are. Mrs. Nguyen: Will Jared be okay? The infusion has been stopped and the dose has been corrected. I will personally ensure that everything possible be done to prevent something like this happening again with your son. We will bring our findings up with the quality management team of our hospital to make sure it does not happen again with any other patients. Again I am very sorry and I take full responsibility for the mistake. Mr. Nguyen: We appreciate your honesty. We are just so concerned about our son. I understand, and if I was in your position, I would also be upset. We will check his labs and monitor him closely. Mr. Nguyen: When will you restart his chemotherapy? If he is still doing well tomorrow, we will restart his chemotherapy regimen then. You are welcome to call me at my direct office number when you have questions or concerns. I will come by and see you all tomorrow morning. Do you have any more questions at this time? Mrs. Nguyen: No. Thank you for your time.

Case Vignette 8.2.3 Conclusion Jared’s chemotherapy infusion was restarted the next day at the correct dose. Though he did suffer from expected side effects, his regimen was successful. He went on to have a complete resection of his tumor and was discharged home to his grateful parents. At a 12-month follow-up appointment, the Nguyens confide to you

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that their friends had urged them to consider a malpractice suit after the incorrect chemotherapy dose was given. They did not pursue any legal action.

Learning Issues 1. Psychological and social factors influencing doctor–patient communication A patient’s style of interaction with his or her physician can be a reflection of his or her culture. The effect of a patient’s culture and family values on the patient– physician relationship has been well studied. While most Latin Americans may welcome a warm handshake and direct eye contact from their physician, many Asian Americans may feel uncomfortable with this display of familiarity. Thus it is important for all healthcare professionals to become familiar with the cultural norms of the populations they most commonly encounter. Please refer to Chap. 14 for a further discussion of culture in medicine. There are three general models of physician–patient interactions. Active–passive

Guidance–cooperation

Mutual participation

Physician Makes and implements all decisions

Makes many of the decisions

Patient

Patient’s actions guided by physician

Works with patient to make decisions and achieve goals Works with physician to make decisions and achieve goals

Unwilling or unable to participate in decisions

The active–passive model was more common in the past. There is a movement toward the mutual participation model. 2. The impact of relationship on malpractice risk Research has shown that practicing patient-centered medicine can reduce the risk of litigation against physicians. Physicians who are able to communicate effectively, display appropriate empathy, and collaborate with their patients have higher patient satisfaction. Higher patient satisfaction correlates with decreased malpractice-lawsuit intentions. Improves patient–physician relationship

Hurts patient–physician relationship

Timeliness Empathy Personal responses Positive collaboration

Perceived unavailability, perceived “hurry” Perceived lack of caring Dismissing patient’s concerns Lack of collaboration

3. Physician–patient alliance and its effect on outcome Many studies have shown a correlation between a positive physician–patient alliance and a good outcome. The quality of the relationship and the existence of a personal connection between the doctor and the patient affect the patient’s


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compliance with care. Strong alliance is associated with increased compliance and thus reduced symptom severity and improved health (Brock & Salinsky, 1993; Neale & Rosenheck, 1995; Tongue, Epps & Forese, 2005). Conceptually, the physician–patient alliance involves mutual respect, attentiveness, and effective communication. There is a multitude of data that support that good communication leads to better alliance, and better alliance is linked to improved adherence to the physician’s recommendations, including medications, treatment regimen, and follow-up. 4. Specific factors affecting alliance A number of researchers have studied physician–patient alliance. Some studies ask patients to rate their satisfaction with their doctor. Other studies record the physician–patient encounter and study the recorded dialog. Bernstein and Bernstein (1980) found that the expression of concern by the physician is important to patients in forming rapport. Explanations of the purpose behind tests and the rationale of treatment are also important (Cormier, Cormier and Weisser, 1984). Improving communication skills of physicians can lead to increased time efficiency with visits. Patients respond more positively to physicians trained in communication skills and express higher levels of satisfaction. The amount of time that physicians allow patients to describe their medical concerns also affects alliance. Numerous studies have found that physicians’ verbalizations take up the majority of the sessions. Patients sometimes speak less than one tenth of the time spent with the physician. One study revealed that when physicians asked an average of 27 questions, patients were allowed to ask only 1.5 questions per visit (Waitzkin, Cabrera, Arroyo de Cabrera, Radlow & Rodriquez, 1996). Many physicians also believe that they spent 50 % of their time explaining, informing, and educating. Studies consistently have shown that physicians spend less than 10 % of their interaction time performing those activities (Bain, 1976; Davis, 1971; Fremon, Negrete, Davis & Korsch, 1971; Stiles, Putnam, Wolf & James, 1979; Waitzkin, 1984, 1985). Physicians also self-disclose information about their personal or professional experiences. Patients view these self-disclosures as generally unhelpful and at times disruptive (McDaniel et al., 2007). As many as 45 % of the patients are highly dissatisfied with the level of information their physician gave them regarding their diagnosis (Phillips, 1996). The literature suggests that physicians need to improve their communication patterns by offering patients more opportunities to clarify their concerns and ask questions. Physicians also need to avoid interruptions, give patients more information on their diagnoses, and have increased awareness regarding the impact of their interpersonal style and self-disclosures on patient satisfaction. 5. Apology Medical errors occur fairly often. After a medical professional detects an error or makes a mistake, should he or she apologize to the patient? Apologies in medicine are sometimes controversial because some physicians (or their lawyers)

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believe that an apology is the same as an admission of malpractice and may be used against them in a lawsuit. Although research has not yet answered the question about increased risk of malpractice in individual cases, there are several compelling reasons for a physician to consider apologizing to patients and families when he or she makes a mistake that harms a patient. Because an apology communicates an acknowledgement that the doctor made a mistake and intends to do better in the future, it maintains the trust between the doctor and the patient. If the patient becomes aware of a mistake and the doctor avoided talking about it, the patient may wonder if this doctor can be trusted to be open and honest in the future. Open and honest communication is the hallmark of a healthy and effective doctor–patient relationship. Another reason for a doctor to consider an apology for an error is for his own well-being. Doctors are caring people and can be deeply affected when a patient is harmed by a mistake. An apology allows the doctor to express his regret and know that, despite the error, he did the honorable thing by offering a sincere apology. Sometimes a heartfelt apology will allow the doctor and the patient to talk about the problem in ways that deepen their relationship and allow the doctor to become more effective in the future. Recent government rules require hospitals to inform patients of errors in their care. Some doctors and hospitals have started physician-support programs to assist doctors with the skills required for disclosing a medical mistake and making an effective apology (see references).

6. Communication of bad news Because of the legal and ethical ramifications, bad news (such as testing and diagnostic information) should be delivered with sensitivity and skill. An article published by Medical Economics (Grandinetti, 1997) describes a six-step process with the mnemonic FRAMES used in difficult patient encounters. The following is an illustration of the FRAMES model. As a family doctor, you examine a 4-year-old child brought in by her mother for required preschool immunizations. You notice the mother appears anxious asking you to just give the child the shots because they have to catch the bus. She promises to bring the baby back next month for an exam. You tell her that you understand her concerns but in order to document that the child is healthy enough for school, you need to do a quick examination. As you remove the child’s clothes, you notice two large bruises encircling both upper arms and a few marks on her back resembling cigarette burns. F (Feedback): “These bruises and scars on your child are very concerning to me. Last time you came in for your exam, you had a black eye and some bruises on your leg. You’ve denied any abuse or physical aggression before. But I cannot ignore what is happening to your child. Has someone been hurting Amanda?” R (Responsibility): Allow the patient to take responsibility by responding to your feedback.


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A (Advice): Offer patient advice. “I am very concerned for you and your child’s safety. I encourage you to speak with a social worker today who can offer you some assistance and safe resources.” M (Menu): Offer patient a menu of options. “I will have to call child protective services regarding Amanda’s injuries. They may be able to offer you additional resources and advice as well. Would you like a representative to meet with you in the office? Or would you prefer to see a social worker from our clinic first?” E (Empathy): Provide patient with empathy as they will need to feel supported during this stressful time. “This must be an extremely difficult and scary time for you and Amanda. I admire your resilience.” S (Self-Advocacy): “You have made it through some very difficult times in your life and have had to make some tough decisions. I know you’ll be able to do what’s best for you and Amanda.”

Review Questions 1. Which of the factors listed is the most likely barrier to effective communication in the following vignette? Physician: How are you Maurice? Patient: Fine doctor. I’m a little nervous about the test results though. Physician: That is understandable. You have been in a lot of pain. What do you think the problem is? Patient: I really don’t know doc. What did the tests show? Physician: The results indicate that you have peripheral artery disease. The pain you experienced is due to intermittent claudication. We’ll start you on Adalat and that should help. Patient: What is intermittent claudication? Physician: Peripheral arterial disease is a common manifestation of atherosclerosis. Intermittent claudication is a symptom of peripheral arterial disease . . .. (a) The physician did not demonstrate sensitivity to gender, racial, and cultural diversity (b) The physician attempted to elicit the patient’s view of the health problem (c) The physician utilized medical terminology to explain a patient’s health problem (d) The physician used silence and nonverbal facilitation to encourage the patient’s expression of thought and feelings (e) None of the above 2. In case vignette 8.1.1, which of the following could the doctor have done to reduce his legal risk? He should have (a) documented more thoroughly (b) rectified medical errors to the patient in a timely manner

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(c) provided false reassurance to prevent her from worrying unnecessarily (d) provided inadequate information (e) dismissed patient’s concerns

Answers 1. c, 2. b

Case table 8.1.1 Miriam Phillips 1

What are the facts? Running an hour late with no explanation Limited eye contact No greeting No instruction Doctor stands instead of sitting at eye level of patient Doctor interrupts frequently Doctor uses doctor speak Does not explain diagnosis or procedures (pt may not know what an ultrasound is or why the labs are needed). Hands pt the lab sheet without explaining what she needs to do next Asks several questions before allowing patient to answer Poor follow-up instructions (did not explain what to expect or look out for) Not accounting for age and culture (do not respond well to rapid fire questions) Hurries patient out of office Dismisses patient’s anxiety

What are your hypotheses about this relationship? How does the patient feel? Poor rapport Patient feels anxious




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Case table 8.1.2 Miriam Phillips 2 What are your hypotheses about this relationship? How does Mrs. Phillips feel?

What are the facts?



Dismisses patient’s anxiety False reassurance (reactive) Poor follow-up directions (should patient go to ER? Admission?) No greeting No eye contact No expression of medical concern Does not explain why the surgeon is needed Previous reassurance backfires on Dr. Smith (you said my condition was not serious) False reassurance again

Case table 8.1.3 Miriam Phillips 3

What are the facts?

What are your hypotheses about this relationship? How does the son feel?



Poor follow-up with son Lost opportunity to establish rapport with family

Case table 8.2.1 Jared Nguyen 1

What are the facts? Gathers information prior to seeing patient Introduces self and greets parents Demonstrates compassion Invites questions

What are your hypotheses about this relationship? How do the parents feel?



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Case table 8.2.1 (continued)

What are the facts?




Finds out current level of understanding of illness Examines level of prior knowledge Conserves time by not re-explaining parents already know Does not make assumptions about what patient knows Performs education Explains things during the examination Answers questions Provides parents with number and contact info

Case table 8.2.2 Jared Nguyen 2

What are the facts? Explain options, risks, and benefits Parents kept informed Doctor responds to patient’s emergency in a timely manner Doctor admits and explains mistake immediately and tells them how it was corrected Initiates investigation and keeps communication open Assures the family that a lesson has been learned from this mistake and the quality management team will be consulted to prevent future incidents Takes full responsibility for the mistake


What specific What do you information want to would you like know next? to learn about?


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Case table 8.2.3. Jared Nguyen 3

What are the facts?

What are your hypotheses about this relationship? How does the patient feel?



Friends urged Nguyens to file a malpractice lawsuit Parents did not sue

Bibliography Bain, D. J. G. (1976). Doctor–patient communication in general practice consultations. Medical Education, 10, 125–131. Bernstein, L., & Bernstein, R. S. (1980). Interviewing: A guide for health professionals (3rd ed.). New York: Appleton-Century-Crofts. Brock, C. D., & Salinsky, J. V. (1993). Empathy: An essential skill for understanding the physician– patient relationship in clinical practice. Family Medicine, 25, 245–248. Cormier, L. S., Cormier, W. H., & Weisser, R. J. (1984). Interviewing and helping skills for health professionals. Belmont, CA: Wadsworth. Davis, M. S. (1971). Variation in patients’ compliance with doctors’ orders: Medical practice and doctor–patient interaction. Psychiatry in Medicine, 2, 31–54. Engel, G. L. (1997). From biomedical to biopsychosocial: Being scientific in the human domain. Psychosomatics, 38, 521–528. Fremon, B., Negrete, V. F., Davis, M., & Korsch, B. M. (1971). Gaps in doctor–patient communication: Doctor–patient interaction analysis. Pediatric Research, 5, 298–311. Grandinetti, D. (Ed.) (1997). Handling patients you wish you didn’t have. Medical Economics, June 9, 142–164. Lazare, A. (2004). On apology. Oxford: Oxford University Press. McDaniel, S. H., Beckman, H. B., Morse, D. S., Silberman, J., Seaburn, D. B., & Epstein, R. M. (2007). Physician self-disclosure in primary care visits: Enough about you, what about me? Archives of Internal Medicine, 167, 1321–1326. Neale, M. S., & Rosenheck, R. A. (1995). Therapeutic alliance and outcome in a VA intensive case management program. Psychiatric Services, 46, 719—721. Phillips, D. (1996). Medical professional dominance and client dissatisfactions. A study of doctor– patient interaction and reported dissatisfaction with medical care among female patients in 4 hospitals in Trinidad and Tobago. Social Science and Medicine, 42, 1419–1425. Sorry works coalition: sorryworks.net. Stiles, W. B., Putnam, S. M., Wolf, M. H., & James, S. A. (1979). Interaction exchange structure and patient satisfaction with medical interviews. Medical Care, 17, 667–681. Tongue, J. R., Epps, H. R., & Forese, L. L. (2005). Communication skills for patient-centered care. The Journal of Bone and Joint Surgery, 87A, 652–658. Waitzkin, H. (1984). Doctor–patient communication: Clinical implications of social scientific research. Journal of the American Medical Association, 252, 2441–2446. Waitzkin, H. (1985). Information giving in medical care. Journal of Health and Social Behavior, 26, 81–101. Waitzkin, H., Cabrera, A., Arroyo de Cabrera, E., Radlow, M., & Rodriguez, F. (1996). Patient– doctor communication in cross-national perspective. Medical Care, 34, 641–671.

Chapter 9

Ethics and Professionalism Jacob Doris and Marin Gillis

Ethics and morality are features of human life, thinking, and concern. Questioning how one should rightly act and how one can be a good person and live a good life are compelling because as human beings we do not act simply on impulse or instinct and we do not live alone: how we act and what we believe about right and wrong cannot help but affect others. The study of ethics helps us in two ways: to understand the reasons that medical practice has developed as it has and to be able to defend our actions if called upon to justify them. It is important to note the distinction between law and morality or ethics. Consider that the Supreme Court’s Roe v. Wade decision did not settle the question of whether abortion is morally permissible. Whatever the law may be, we can always ask what the law should be. Law codifies society’s majority practices, and practices as well as majorities change. Furthermore, not every act that is illegal is also immoral, for example, civil disobedience; and conversely, not every act that is immoral is also illegal, for example, lying to your spouse. Codes of professional ethics, for example, the AMA Code of Medical Ethics, are basically sets of rules and tend to be much the same as standards of good practice, such as, physicians maintaining a commitment to medical education. Sometimes codes do include moral imperatives, for example, “a physician shall support access to medical care for all people” (Council on Ethical and Judicial Affairs, 2007). At the end of this chapter, students will be able to 1. 2. 3. 4. 5. 6. 7. 8.

Identify two reasons why the study of ethics is important Conceptually distinguish ethics and the law Describe four domains of ethical assessment Identify four conceptual tools to construct ethical assessment Distinguish the four principle of bioethics Understand the ethical guidelines when principles of bioethics conflict Apply the four principles of bioethics to clinical cases Apply the ethical guidelines in a clinical case of conflicting bioethical principles

J. Doris Resident in Psychiatry, University of Nevada School of Medicine


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The following cases illustrate how actions in medical practice may be ethically assessed according to the four principles of bioethics.

Case Vignette 9.1.1 Robert Sanchez You are a neurologist seeing Mr. Roberto Sanchez, a financially stable, frail 48-year-old veteran whom was referred to you by his primary care physician after complaining of weakness over the past few months. He has been experiencing a gradually progressive weakness that has gradually involved both his arms and legs. On his first office visit, Mr. Sanchez notes complaints of twitching, muscle cramps and that his muscles appear to be “going away.” On neurological exam, you note hyperreflexia, upgoing babinski reflex, and a completely intact sensory exam. You order a battery of tests, including heck and head MRIs, CSF analysis, and electromyelography (EMG). Mr. Sanchez returns to your clinic, where you inform him that the tests support your suspicion that his diagnosis is amyotrophic lateral sclerosis, or ALS, commonly called Lou Gherig’s disease. This is a progressive degeneration of motor neurons with no cure and a 3- to 5-year prognosis. Mr. Sanchez learns during the next few visits that eventually he will not have the strength to breathe adequately on his own, and that he will require long-term mechanical ventilation to sustain life. Over the proceeding months he undergoes treatment with the drug riluzone and remains in a positive attitude. He also continues to display intact mentation and makes clear on numerous occasions that when the time comes, he does not wish to be placed on long-term mechanical ventilation.


Case Vignette 9.1.2 Continuation Eventually, Mr. Sanchez’s condition deteriorates, and his weakness progresses to include the muscles of respiration. He initially elects to continue with his decision about life-sustaining measures and receives only nasal positive-pressure ventilation. In his most recent office visit, Mr. Sanchez looks to be in rapid decline. At the previous visit, you helped make arrangements for hospice care, but at this visit, he asks what his options are to extend his life. You gently explain that no intervention will extend his life beyond a few days to weeks, and that once this decision is carried through, he will no longer be able to survive off the ventilator. He tells you that he

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is “not ready to say goodbye.” His life expectancy is days to weeks, and the quality of his life is very poor.


Case Vignette 9.1.3 Conclusion You make arrangements for an immediate tracheostomy for mechanical ventilation. He is admitted to the VA hospital ICU and placed on mechanical ventilation and parenteral nutrition. His family visits him daily. Although he is unable to speak, he is able to make eye contact with the family. He dies13 days later.

Learning Issues There are four domains of ethics assessment: (1) action; (2) consequences of action; (3) the character of the person (moral agent) who is acting or contemplating action; and (4) the agent’s motives for acting or contemplating action. In order for an agent or an action to be the object of ethical assessment, that is, in order to be able to evaluate whether the agent acts from beneficial, malicious, or neutral will, or whether the agent’s actions are determinable as morally permissible, obligatory, or prohibited, the agent has to be responsible for his or her actions. To be responsible for one’s actions, motives, or character, to be considerable as a moral agent, one has to be autonomous. To be autonomous is to be free from coercion and compulsion, to be able to act and think voluntarily, and to act rationally, in other words, to have logical reasons for what one does. When we ethically assess action, decision, and motivations in medicine, we rely on the following tools: (1) logic, to assess the reasoning behind the determination of the morality of an action, motive, or character; (2) conceptual analysis, which involves defining, elucidating, comparing, and contrasting the ethical concepts of the cases; (3) consistency and case comparison, where we treat like cases alike unless a morally relevant difference is found; and (4) reasoning from principles (Hope, 2004). In medical ethics, reasoning from four principles, dubbed the Four Principles of Bioethics by Thomas Beauchamp and James Childress, is a common way to start ethical assessment in medical practice. The four principles are (1) respect for patient autonomy; (2) beneficence, acting to promote what is best for patient (the standard of due care is grounded by this principle); (3) nonmaleficence, acting not to harm the patient; and (4) justice, including distributive justice, for example, the

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equal distribution of benefits and burdens, respect for the law, rights, and retributive justice, that is, punishment (Beauchamp & Childress, 2001). Principles often conflict, such as when a patient autonomously refuses a treatment that the physician believes would have the best health outcomes. This conflict is between the imperative to respect a patient’s autonomy (right to refuse treatment) and the principle of beneficence (acting to promote what is best for the patient). The following guidelines are broadly recognized as central in navigating conflicts. 1. The interests of the patient count most (interests = autonomy, beneficence, and nonmaleficence) 2. Respect for patient autonomy outweighs beneficence and nonmaleficence toward a patient (autonomy > beneficence, nonmaleficence) 3. The interests of others may outweigh respect for patient’s autonomy 4. If harms and benefits are proportionate, duties of nonmaleficence outweigh those of beneficence (Mahowald, 2006). In this case, as a physician you have acted to respect the autonomy of the patient. First, Mr. Sanchez appears to have made a decision about his treatment with informed voluntary consent. You explained the treatment alternatives to the patient, including the risks and benefits of each option, Mr. Sanchez indicated that he understands what he was told, Mr. Sanchez has no symptoms of depression, and he does not appear to be coerced into making this decision because neither family nor finances appear as relevant to his considerations. Second, you acted on the patient’s decision. This case can also be related to the question of health care rationing: a distributive justice issue. Health care resources are scarce, and health care costs are rising due to new medical technologies and population growth. Because much of the expensive health care technologies are used to prolong the lives of the critically ill, usually elderly people in the last years of their lives, the question of rationing health care resources, to allocate a certain amount of resources that can be accessed by any particular person, arises. Those in favor of distributive justice advocate a policy that balances an equal share for all people against a fair distribution of health care resources among those in need. This raises issues such as the merit of allocating health care resources only to health care or also to other areas that promote healthy lifestyle decision-making. It also implies the existence of a minimal acceptable amount of health care for all members of society.

Case Vignette 9.2.1 Presenting Situation: Mark Handon You are a family physician who has been seeing Mr. Mark Handon, 48, whose medical problems include hypertension and stable angina, for which he takes, among other things, a nitrate drug medication. He is in your office for a routine follow-up visit. Accompanying him on this and prior visits is his wife, Nora Handon. On this office visit, she tells you that her husband has a “problem” for which he would like help. Mr. Handon appears sheepish while speaking, and his wife interjects a description of symptoms consistent with erectile dysfunction. Mr. Handon’s wife


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states that their relationship has suffered due to this problem and that she would like him to have a medication to help. His wife asks that you prescribe him that medication “in the commercial with the football and tire” for his problem. Having seen the commercial yourself, you know she is referring to a medication prescribed for erectile dysfunction. While looking at Mr. Handon’s chart, you notice that this medication in combination with his nitrate medication could drop his blood pressure and cause a heart attack.


Case Vignette 9.2.2 Conclusion You indicate to Mr. Handon at this time that you will not prescribe him this drug due to the risks of drug interactions that could endanger his health. You offer to refer him to a urologist who can better assess his erectile dysfunction and make clear that you can offer additional resources (reading, a psychology referral) if he would be interested in other approaches.

Learning Issues The physician has acted according to the principle of nonmaleficence. The physician acted intentionally to not create a needless harm or injury to the patient, either through acts of commission or omission. In common language, an action is regarded as negligent if one imposes a careless or unreasonable risk of harm upon another. The physician may have felt conflicted, since most people in service-oriented professions want to please the people they serve, and withholding a desired treatment may disappoint or anger the patient. Clarity about the physician’s duty to nonmaleficence can guide clinicians through those types of conflicts. At first glance, a case such as this may seem to act against patient autonomy in favor of nonmaleficence, but in actuality, autonomy has not been an issue for it. Patients’ autonomy is based in their right to control over their own body by leaving it unchanged except at their discretion. This case does not conflict with a patient’s right to autonomy because it does not have the physician forcing an action on the patient, but rather withholding an action that could cause him great harm. A patient with decision-making capacity has a right to refuse having a beneficial treatment affect their body, but does not have the right to demand a detrimental treatment be used on them. In the first situation, they are maintaining their body unchanged as they see fit. In the second, they are requesting an alteration in their bodily process. With many treatment options, there is a balance between possible benefits and harms and, as noted above, when benefit and harm are equal, physicians should act to maintain nonmaleficence.

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Case Vignette 9.3.1 Willa McTavish You are an ER physician presented with a 46-year-old adult woman, Ms. Willa McTavish, brought into the ED by EMS after a motor vehicle collision. Your physical exam reveals that in addition to severe hypotension and tachycardia, she is pale with signs of an acute abdomen, most notably, extreme tenderness to palpation and distension. You suspect internal bleeding. A stat CBC shows a critically low hematocrit. The best chance of saving her life is a blood transfusion treatment. You explain the situation to Ms. McTavish, and she tells you that her religious principles require that she not accept the transfusion and that she is willing to die to follow her religion.

Please proceed with the problem-based approach! You speak with Ms. McTavish’s family. They report that she has no psychiatric history suggestive of problems with depression or psychosis. They confirm that Ms. McTavish was baptized into the Jehovah Witnesses a few years ago and practices that religion actively. You use the Internet to confirm the church standards on refusing blood transfusions.


Case Vignette 9.3.2 Conclusion You initiate infusion of blood alternatives and do not give her a blood transfusion. Ms. McTavish undergoes emergency surgery for internal injuries and survives the surgery. After a lengthy hospitalization, she is discharged to a rehabilitation center and eventually, home.

Learning Issues The physician has been confronted with a conflict in this case. The principle of respect for patient autonomy would direct the physician to respect the patient’s right to refuse treatment and therefore not give her the transfusion. But since this treatment appears critical to saving her life, and the physician is committed to the principle of beneficence, which is to act to benefit the patient and avoid harm, the


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physician would give her the transfusion. Further, the physician is also committed to the principle of nonmaleficence and not administering the transfusion would cause the patient grave harm. When such a conflict arises, the patient’ right to autonomous control over her own body outweighs the principles of beneficence and nonmaleficence, even when the consequences of this respect are likely to cause the patient grave harm. In the second installment of this case, the physician clarified that the patient was not making a decision to refuse potentially life-saving treatment as a result of psychotic thinking or depression. He took further steps to ensure that the patient’s wishes were consistent with her behavior and beliefs. The physician in this case acted according to the principle of respect for patient autonomy.

Case Vignette 9.4.1 Presenting Situation: George Greely Mr. Greely is a 58-year-old homeless man well known to the emergency room due to his frequent admissions related to alcohol intoxication. Tonight he comes in by ambulance because he was found face down in the street. He smells heavily of alcohol and poor hygiene. The intern on call for the ER, Norm, is watching the World Series in the on-call room when gets a page. When the nurse tells him it is Mr. Greely, he groans and decides he doesn’t even need to put on a scrub shirt over his heavy metal band t-shirt since it’s Mr. Greely. Mr. Greely is not very responsive to questions and uncooperative with Norm’s brief screening physical exam (listening to heart and breath sounds). Mr. Greely has an abrasion on his forehead and some blood in his hair. Norm decides to order some labs and to have the nurse page him in the call room when the labs come back. He also orders “Shower patient when awake.”


Case Vignette 9.3.2 Continuation A few hours later, Norm is asleep and the nurse pages him again. He calls her phone number and crossly asks, “What is it that is so important?” She tells him that the labs show an alcohol level of 0.22, hypokalemia, elevated liver function tests, and an elevated white blood cell count. She reports Mr. Greely is sleeping peacefully in a quiet corner of the ER. Norm asks her to call the internal medicine resident and tell him that “Our friend Mr. Greely is coming in for a tune up and he doesn’t smell good.”

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The next morning, Norm receives a stat page to the morning report conference room. Mr. Greely has a subdural hematoma with midline shift and is currently in surgery for evacuation of the hematoma. The internal medicine chief resident is furious that Norm did not detect the brain injury last night and says so in front of all of the internal medicine residents present. In addition, she tells the entire room “Norm really blew it in the ER. I’m sure Greely’s family will want to know who to sue.”

Learning Issues Professionalism is a term that describes a collection of physician duties. Some of these duties are put into the form of “rules” but many are considered to be so basic to the function of the physician that they are felt to be implicitly understood. In this case, we note several deviations from professional standards. An obvious problem in the care of Mr. Greely is that the patient was not put first. The intern cut corners with the exam and assessment in order to watch the World Series and to sleep. Other lapses on the part of the intern include lack of professional appearance in the clinical setting, the disrespectful tone used to describe the patient and his disrespectful phone manners with the nurse. Another significant lapse in professionalism is that the intern delegated a communication responsibility to a nurse instead of making the call to the admitting resident himself. Professionalism standards are particularly important when transferring care of a patient. The physician who initiates the transfer has an obligation to let the receiving party know about the patient’s problems and to continue to take responsibility for the patient if the transfer is unsuccessful. The Federal Government passed the Emergency Medical Treatment and Labor Act to ensure that transfers between hospitals follow these principles. The next morning, the chief resident violated principles of professionalism, by impugning Norm’s reputation and failing to maintain a professionally composed demeanor when addressing an important patient care problem. She appeared to intend to publicly shame him instead of providing respectful feedback. There are many additional aspects of professionalism that are important in every day interactions with patients, colleagues, and outside entities. The table below offers some examples of these considerations. Thoughtful publications on professionalism have been developed by the American Board of Internal Medicine (see references). Elements of professionalism: Duties to patients, colleagues, self and everyone in work environment


Respect Appearance Demeanor Language Consideration Responsibility Put patient first Follow-through Conscientious

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Examples Neat, professional Composed, friendly Not overly familiar, no swearing Attention to the needs and feeling of others; discretion in discussing differences with colleagues Defer own needs when in conflict with patients needs Following up on labs, reports, patient follow-through on treatment plans Comprehensive patient exams, getting records/ communicating with other providers

Follow rules Honesty Up to date Accountability

Institutional bylaws, professional standards, state laws Clear communication of the facts and what is unknown; disclosing error Maintaining current knowledge and skills; self-study Accepting responsibility for performance and outcomes

Responsiveness Timely Alacrity Service Support

Responding to requests in a timely manner, avoid delays Express willingness if available Working to meet the needs of the community, institutions, and profession Supportive of colleagues and institution

Review Questions 1. Which of the following statements most closely correlates to respecting patient autonomy? (a) Withholding information temporarily from a patient because the said information may worsen his or her clinical condition (b) Doing what is right for the patient (c) Allowing a patient to choose to withhold life-sustaining treatment for their condition (d) Informing patient of relative risks versus benefits of an indicated treatment 2. Which of the following is not one of the four main principles of biomedical ethics components as originally described by Beauchamp and Childress? (a) (b) (c) (d)

Beneficence Respect for autonomy Justice Duty to warn

3. You decide not to prescribe a potentially beneficial medication because of the large potential for an injurious negative outcome. What principle of medical ethics would most closely correlate with this decision? (a) (b) (c) (d)

Duty to patient Nonmalificence Autonomy Beneficence

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4. Which of these is not a tool physicians use to assess ethical choices? (a) (b) (c) (d)

Case comparisons Reasoning from principles Anecdotal evidence Conceptual analysis

5. A new law is passed stating that a certain commonly prescribed pain medication can only be prescribed by a board-certified pain specialist. You have a patient who has previously been found to gain pain relief from this drug and failed to gain relief from any other. If this patient is waitlisted to see a pain specialist for 2 months past his last refill, what is the ethical choice regarding his prescription? (a) Do not prescribe the drug because it is illegal and the law is never unethical (b) Do not prescribe the drug because it is not in the patient’s best interest for you to go to jail (c) Prescribe the drug to prove a point about an unjust law as a method of civil disobedience (d) Prescribe the drug because it is in the patient’s best interest and they will suffer harm without it 6. Which of these is most important to a health care decision for a psychologically fit patient? (a) (b) (c) (d)

The likelihood of an action hurting a patient The likelihood of an action benefiting the patient The patient’s desire for a certain course of action The patient’s family’s desires for a certain course of action

7. Which of these is not an ABoIM Element of Professionalism? (a) (b) (c) (d)

Responsiveness Respect Responsibility Relationships

Answers 1. c, 2. d, 3. b, 4. c, 5. d, 6. c, 7. d

Suggested Readings American Board of Internal Medicine Professionalism Project. (2001). http://www.abim.org/ pdf/profess.pdf. Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.) New York: Oxford University Press.


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Council on Ethical and Judicial Affairs (CEJA). (2007). AMA code of medical ethics. http://www.ama-assn.org/ama/pub/category/2498.html. Retrieved August 20, 2007. Hope, T. (2004). Medical ethics: A very short introduction. New York: Oxford University Press. Jonsen, A. R., Siegler, M., and Winslade, W.J. (2002). Clinical ethics: A practical approach to ethical decisions in clinical medicine (5th ed.) New York: McGraw-Hill. Mahowald, M. (2006). Bioethics and women. New York: Oxford University Press. Kayhan, P. (2006). Healing as vocation: A medical professionalism primer (practicing bioethics). Lanham, MD: Rowman & Littlefield. Tong, R. (2007). New perspectives in healthcare ethics: An interdisciplinary and crosscultural approach. Upper Saddle River, NY: Prentice Hall.

Chapter 10

Adherence in Medicine Maxwell Takai Frank and Eriko Takai Frank

Most health care providers become frustrated with non-adherent patients early in their training. This chapter examines the problems associated with adherence and offers insights into possible interventions to improve adherence. At the end of this chapter, the reader will be able to 1. Discuss the epidemiology of non-adherence within different patient populations and with respect to specific health domains 2. Understand the importance of maintaining healthy habits with respect to the prevention and treatment of chronic medical conditions (e.g., diabetes, obesity) 3. Recognize clinical situations where non-adherence with treatment recommendations (e.g., lifestyle changes, medication regimens, follow-up appointments) is an important reason for poor clinical outcome 4. Develop clinical evaluation strategies in order to discriminate between different causes of non-adherence 5. Discuss ways of preventing treatment non-adherence and how to successfully intervene when the diagnosis of non-adherence is made

Case Vignette 10.1.1 (Presenting Situation) Kelii Kelii is a 17-year-old male high school senior from Hawaii who has come to your family medicine clinic for a physical exam, which is a requirement for a private college program that he wants to attend this summer. You have not seen Kelii in nearly 3 years. He is a tall but overweight young man, and while asking about HEADSS (i.e., Home, Education/Employment, Activities, Diet/Drugs, Sexuality/Suicide), you ask about his eating and exercise habits. He states that he used to be active in sports when in grade school. However he began college preparatory school at 7th grade, and since then has focused more on his studies. His primary source of exercise occurs three times a week as part of his physical education (PE) classes. Kelii notes, however, that after PE, he is hungry and eats more snacks. M.T. Frank Resident in Psychiatry, Boston University Medical Center


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Lunch is typically fast food, and he snacks on candy bars, chips, and soda throughout a typical day. On physical exam, Kelii is 198 cm in height and weighs 118 kgs. You take a moment and calculate that his body mass index (BMI) is approximately 30. You recall that you are already treating Kelii’s father and grandmother for TypeII diabetes, and take several minutes to explain to the patient his multiple risk factors for contracting this illness. You ask Kelii to come back to the clinic the next morning in order to have blood drawn for labs, and you will call and speak with him about the results when they come in.

Please proceed with the problem-based approach! At this point in the case, it is reasonable to suggest that the patient’s lifestyle and family history contribute to his obesity. Obesity and family history are also important risk factors for diabetes. While public health and primary care recommendations regarding diet, exercise, and healthy body weight are commonplace, the diagnosis of treatment non-adherence is premature in this case because specific behavioral health prescriptions have not been made to Kelii regarding healthier habits. Medical advances of the twentieth century are responsible for having brought many formerly fatal, acute illnesses under control, and clinical attentions are increasingly concerned with the prevention and treatment of chronic medical conditions, such as diabetes. It is within this environment that the modern prescriptions for harm reduction, primary prevention, and behaviorally oriented health care have flourished. Healthy habits are not solely the concern of older adults, however; the bulk of existing research supports the conclusion that initiating and maintaining healthy habits is of vital importance for young adults (Dubbert, Rappoport, & Martin, 1987). In addition, reviews of US mortality risk factors have concluded that more than one-half of all deaths have direct behavioral health determinants, and behavioral risk factors have been linked to many cancers, cardiovascular disease, lung and liver disease, motor vehicle-related fatality and injury, and sexually transmitted disease, including acquired immunodeficiency syndrome (AIDS) (e.g., as reviewed by Gochman, 1997). The vignette at this point is an excellent opportunity to review the components of a well-adolescent history, for which risk-assessment acronyms such as HEADSS are commonly used.

Case Vignette 10.1.2 Continuation A few days later, you review the results from Kelii’s fasting labs: Afterwards you call the patient at home and arrange for a follow-up visit.

10 Adherence in Medicine Sodium: 141 mEql/l BUN: 12 mg/dl Creatinine: 1.0 mg/dl

135 Bicarbonate: 24 mmol/l Glucose: 156 mg/dl Glycosylated Hb: 7.0 %

Cholesterol (total): 245 mg/dl LDL: 170 mg/dl Triglycerides: 239 mg/dl

When you enter the examination room where Kelii is waiting, you notice that he looks anxious. After reviewing the test results with him, you conclude “Kelii, you likely have Type-II diabetes and this means that you’re going to have to make some changes in your lifestyle. Your current diet and exercise habits are for a big part of this illness, and so it’s very important that you make healthier choices.” You make mental note to schedule appointments for Kelii with the dietician and diabetes nurse educator before he leaves. You inform Kelii that the diabetes nurse will show him how to use the glucose monitor, lancets, and test strips which you will prescribe for him today, and that you want him to monitor and record his blood sugars every morning for the next 4 weeks. You conclude your visit, and say to Kelii “Come back in one month and bring all your blood sugar records so I can see how you’re doing. Do you have any questions at this time?” “. . . Nah, Doc,” he replies and departs. You next see Kelii 4 weeks later. You received word from the dietician and diabetes nurse educator that he never made his appointments, and you begin to wonder if Kelii is participating in his treatment. Kelii arrives on time for his appointment and you again note that he looks anxious. You ask about his success with the changes you prescribed last month. “Gee, Doc, I never thought I could make these changes, so I never tried. There’s so much you wanted me to do. I just couldn’t do it. Besides, I feel healthy! Why should I care about my sugar levels?”

Please proceed with the problem-based approach! This case illustrates how, for any given patient and with respect to any particular health behavior, non-adherence is a heterogeneous construct. For example, while Kelii did not perform blood glucose monitoring as requested, he succeeded in arriving on time for each of his appointments with you, but did not show up for his visits with the dietician or nurse educator. Non-compliance with diabetic self-care is extremely common. Although self-monitoring of blood glucose is a standard regimen component for adults with Type-II diabetes, compliance estimates range from 5 to 44 % (Kennedy, 2001) with lowest rates reported by patients who do not yet require medication (Harris, 2001). Concerning the nature of a given prescribed regimen, it is generally accepted that the more complex a prescription is perceived to be, the less likely it is that patients will be successfully adherent. When assessing Kelii’s risk for noncompliance, it is important to recall that examples of noncompliance often do not have an explicit intention to be noncompliant. For example, is a non-English speaking patient who cannot read the instructions

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on his pill bottle less compliant than the uninsured patient who chooses to feed his children instead of fill a prescription? How about the busy executive who misplaces his prescription versus the carefree adolescent who neglects to fill his prescription in first place? Each is an example of medication non-adherence, yet each scenario invites different anticipatory and corrective actions by the clinician who is intent on improving adherence.

Case Vignette 10.1.3 Conclusion You feel yourself becoming frustrated as you contemplate how to proceed, when Kelii continues “You also keep referring to this ‘Type-II diabetes’ and I still don’t know what you mean. Yeah, my Dad’s also got it, but he sure as heck doesn’t talk about it. How can I be sick with this disease if I don’t feel sick?” You take a moment to let Kelii’s words sink in, and begin to appreciate how you may have contributed to his noncompliance by failing to explain things in simpler terms, and by not assessing his thoughts and feelings more carefully. When you are finished, you ask Kelii to repeat your explanation using his own words. Afterwards Kelii sighs deeply and jingles the change in his pocket. “I think I understand a little better, Doc, thanks. But I’m still not sure I can make all these changes you want – it’s not cool!” You allow Kelii to discuss other perceived barriers to adherence and suggest several potential benefits of diet, exercise, and weight loss, including the possibility that his diabetes will resolve completely. As you conclude your visit, Kelii smiles and says “Well, Doc, I guess it’s time I started taking better care of myself, and this diabetes might be just the swift kick in the pants that I need.” As he leaves your office, you resolve to make compliance enhancement a higher priority with all your patients, and feel that Kelii wasn’t the only one getting a swift kick in the pants today. The vignette concludes with Kelii disclosing to his doctor the extent of his noncompliance with prescribed treatment and provides some insight into the particular factors at play. The principle diagnoses in this case are obesity, diabetes mellitus, and noncompliance with treatment. For review, according to the DSM-IV, noncompliance with treatment is not considered a mental disorder, but rather is included with such entities as malingering and partner/relationship problems. The diagnosis of noncompliance with treatment can be used when the focus of clinical attention is non-adherence to important aspects of treatment for a mental disorder or general medical condition, and warrants independent clinical attention. Common reasons for non-adherence are shown in Table 10.1. Many theories have been used to explain and predict behavior change, perhaps the most popular within medical contexts is the Stages of Change model (e.g., DiClemente, 1993), which we discussed in Chap. 4, and the associated techniques of Motivational Interviewing (Miller & Rollnick, 2002). According to this model, Kelii starts out in precontemplation, where he does not recognize the problem or the need

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Table 10.1 Common reasons for non-adherence Reason

Examples

Discomfort resulting from treatment Cost of treatment Personal values, religious, cultural, or other beliefs about the advantages and disadvantages of the treatment Maladaptive personality traits or coping styles (please refer to Chap. 6) Presence of comorbid mental illness Doctor–patient variables

Pricking finger with lancet Time commitment, financial burden Alternate beliefs about what the treatment should be Passivity, externalization Major depression, anxiety disorders Inadequate instructions, physician does not elicit patient questions or concerns, low level of rapport

to change. When changes in diet and exercise are seriously considered, Kelii has entered the contemplation stage, which may be followed by preparation, in which he makes a commitment to try to change and takes the necessary steps to enter the action stage, in which he implements the plan for modifying his behavior. Finally, with successful change, Kelii enters a maintenance stage, in which he sustains his lifestyle modifications to avoid relapse and accommodates the new behavior. Stages of change are by no means sequential, and jumps can be made in both forward and backward directions. At the conclusion of the case, Kelii can be seen entering the preparation stage of behavior change, having moved forward from precontemplation at the start of the vignette. As depicted in Table 10.2, with the construction of a bio-psycho-social formulation, it will be possible to target interventions to optimally manage all mechanisms leading to the principle clinical problem in this case: noncompliance with diabetes treatment. Please take this opportunity to construct a bio-psycho-social formulation.

Additional Topics of Interest

r r r r r r r

The role of public health departments and the promotion of healthy lifestyles The collection and evaluation of national health statistics (e.g., Morbidity and Mortality Weekly Report) Patient adherence within both general population and specific age groups Adherence within specific health domains (e.g., diet, exercise, seat belts, bicycle helmets, smoking cessation, substance abuse, chronic disease, obesity) Psychiatric conditions commonly associated with non-adherence (e.g., antisocial or avoidant personality disorders; affective, psychotic, or anxiety disorders; factitious disorder; malingering) America’s “obesity epidemic”, the populations most at risk for developing obesity, and the factors implicated in its etiology Type-II diabetes mellitus: risk factors, pathophysiology, and treatment approaches

Perpetuating factors

Medical condition requiring behavior change (e.g., diabetes) –

Precipitating factors

Primary prevention of lifestylerelated medical conditions – Avoidance of inconvenience associated with compliance

Lack of behavior-specific self-efficacy

Maladaptive personality traits (e.g., denial of illness)

Factor

–

Intervention

Factor

Genetic risk factors (e.g., family history of obesity)

Predisposing factors

Psychological

Biological

Table 10.2 Bio-psycho-social case formulation

Individual counseling; time management strategies

Individual counseling and building of required skill repertoires

Individual counseling; acceptance of personal responsibility

Intervention

Poor communication between patient and health care provider

Modeling of noncompliant behaviors (e.g., family members are not good role models) Embarrassment regarding self-monitoring blood glucose in public

Factor

Social

Routine assessment of patient compliance with prescribed treatment; nonjudgmental orientation

Individual counseling; use of less obtrusive monitoring equipment

Family counseling; compliance enhancement targeted at specific family members

Intervention

138 M.T. Frank, E.T. Frank

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Review Questions 1. Which of the following variables would not be expected to predict compliance with self-monitoring blood glucose (SMBG)? (a) (b) (c) (d)

Having promised someone that you will comply Having successfully practiced SMBG in the past High educational achievement Absence of discomfort during testing

2. Behavior-specific self-efficacy refers to the belief that one is capable of performing the health behavior in question and that doing so will result in better health. (a) True (b) False 3. Which of the following preventive health behaviors would not be recommended to a single, sexually active 21-year-old woman? (a) (b) (c) (d)

Cervical cancer screening Breast self-examination Mammography Bimanual pelvic examination

4. When a patient’s health condition does not respond to your initial medical management, it is useful to inquire about compliance. (a) True (b) False 5. According to the principles of motivational interviewing, which of the following best describes a newly diagnosed diabetic in the “contemplation” stage of behavior change? (a) Actively following an 1800-calorie ADA diet and attending weekly diabetes support group (b) Struggling to resume dietary control after having overindulged during a 2-week vacation (c) Collecting information about alternative and complimentary diabetes treatment approaches (d) Angrily responding to a family member who reminds you that diabetes runs in the family and requests that you be evaluated for this disease

Answers 1. c, 2. a, 3. c, 4. a, 5. c

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References DiClemente, C. C. (1993). Changing addictive behaviors: A process perspective. Current Directions in Psychological Science, 2, 101–106. Dubbert, P. M., Rappoport, N. B., & Martin, J. E. (1987). Exercise and cardiovascular disease. Behavior Modification, 11, 329–347. Gochman, D. S. (Ed.). (1997). Handbook of Health Behavior Research III: Demography, Development, and Diversity. New York: Plenum Press. Harris, M. I. (2001). Frequency of blood glucose monitoring in relation to glycemic control in patients with Type 2 diabetes. Diabetes Care, 24, 979–982. Kennedy, L. (2001). Self-monitoring of blood glucose in Type 2 diabetes. Diabetes Care, 24, 977–978. Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.

Chapter 11

Stress and Health Michael K. Daines and Nikhil Majumdar

Psychological stress is an important contributor to medical problems. Many common health problems can be better managed when the role of stress is identified and managed. At the end of this chapter, the reader will be able to 1. 2. 3. 4. 5.

Provide a working definition of stress Discuss the physiologic and pathophysiologic effects of stress Describe common symptoms of stress Discuss common medical conditions where stress causes or aggravates the illness Discuss adaptive and maladaptive responses to stress

Case Vignette 11.1.1 Presenting Situation: David Rosenthal You are called to the emergency room to provide a psychiatric evaluation of David Rosenthal. The chart describes him as a 43-year-old man who drove himself to the ER and reported to the ER physician the sudden onset of palpitations, profuse sweating, nausea and lightheadedness. He also has had tingling and numbness in his arms and hands. He felt that his chest was tight and it was hard to breathe. The symptoms started suddenly about 4 hours ago and reached peak intensity within about 5 minutes. He was in a business meeting at the time but didn’t want to leave early “because it would have been too embarrassing.” The symptoms gradually resolved after about an hour. He has had four similar episodes over the past 2 months and that he’s becoming progressively worried that he “might drop dead the next time.” His vital signs are: blood pressure 112/84, heart rate 96 and regular, respirations 14 and unlabored and temperature 37.2◦C. An EKG report states “Nonspecific ST segment and T-wave abnormalities. Clinical correlation required.” Blood test results are pending.

M.K. Daines Assistant Professor of Psychiatry, University of Nevada School of Medicine


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Please proceed with the problem-based approach! A review of the DSM-IV-TR criteria for panic attacks and panic disorder indicates that he meets many, but not all, of the criteria. Mr. Rosenthal reports 7 of the 13 symptoms of a panic attack. Only four symptoms are required to meet the definition of a panic attack. He has had four such attacks over the last 2 months, which meets the severity and frequency criteria. He meets the criteria regarding persistent worry about the attacks. However, his condition does not satisfy one important criterion. The presence of a general medical condition has not been excluded. Additional information is required.

Case Vignette 11.1.2 Continuation You introduce yourself, informing him that you are a third-year medical student assigned to the psychiatry service and that the ER doctor has requested a psychiatry consultation. Mr. Rosenthal erupts in anger. “Do you think I’m crazy? Do you think this is all in my head? Nobody has told me what my test results are. Nobody told me a psychiatrist was coming!” How would you handle this situation? This brief exchange demonstrates several valuable lessons. 1. There remains a significant stigma about seeing a mental health professional or having psychological symptoms (see Stigma and Medicine, Chap. 13). 2. When a physician requests a consultation, whether psychiatric or medical, the patient should be informed of the purpose and should give consent. (see The Physician–Patient Relationship, Chap. 8, and Ethics and Professionalism, Chap. 9). 3. Patients frequently do not acknowledge or understand the relationship between life stresses and physical symptoms.

Case Vignette 11.1.3 Continued You acknowledge Mr. Rosenthal’s anger. You validate his frustration about waiting for test results. “I can only imagine what it would be like to be in your shoes. I think I would want to be kept informed as much as possible. Would you like me to find out approximately how much longer it will take?” You make sure that you do not make promises or assurances that are outside your ability to keep. You assure him that the interview is voluntary and confidential. You inform him that life stresses can be important triggers for many illnesses. You offer to talk with him while awaiting the

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test results. Mr. Rosenthal becomes less defensive and replies, “Well, there has been a lot going on lately.” He has been married for 19 years and has two children, who are doing well socially and educationally. Mr. Rosenthal has a close relationship with his mother and his sisters. About a year ago, his father died of a heart attack. He was sad about this loss, but does not feel that he became depressed. Five months ago he received an important promotion and a pay raise. He is working longer hours, but he enjoys his work and likes most of the challenges. However, it does require that he give oral presentations to large groups of strangers which he finds quite anxiety provoking. His family has moved to a larger home, and he misses the friendships from his old neighborhood. Recently Mr. Rosenthal has felt impatient and angry with his wife and children. He doesn’t feel that they appreciate the sacrifices he has made to provide them with a high standard of living. He is not exercising as much as he did before the promotion. He has resumed smoking 8–10 cigarettes per day but drinks no more than two glasses of wine per week and has never used illegal drugs. He asks, “Do you think this has anything to do with my symptoms?” Before you can answer, the ER doctor enters the room and explains that his blood tests indicate that he has had a myocardial infarction.

Please proceed with the problem-based approach! There are multiple factors that are correlated with an increased risk of developing coronary artery disease (CAD). They include

r r r r r r

Abnormalities of lipoproteins Hypertension Family history of CAD Diabetes mellitus Smoking Psychosocial stress

When an individual has two or more of these risk factors, the increase in risk is greater than the sum of risk factors. A detailed review of the diagnosis and treatment of CAD or myocardial infarction (MI) is outside the scope of this chapter. However, the mechanisms by which some of these factors lead to CAD or MI are well described. Studying these mechanisms helps us to understand the role of the stress response in the development of CAD, MI and other diseases. First, it is necessary to propose a working definition of stress. Common usage of the word stress combines the demands of life (“I’m under a lot of stress”) with the physical and emotional reactions (“I’m feeling so much stress”). Usually there is a

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negative connotation to the word stress. For our discussion, we will refer to external demands as stressors and the combination of the physical and emotional effects as the stress response:

r r r r

Stressors can be physical, mental or emotional. Stressors and the stress response can be acute or chronic. A person’s perception of a stressor dramatically affects the physiologic responses. Voluntary human behaviors can moderate or aggravate the effects of these responses.

Normally, the body is in a balanced state known as homeostasis. Though many processes are important in maintaining homeostasis, we will be primarily concerned with the autonomic nervous system (ANS) and the hypophyseal-pituitary-adrenal axis (HPA). The ANS is composed of two divisions: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The SNS is sometimes referred to as “fight or flight.” The PNS can be thought of as the “rest and digest” system. The SNS can be activated by consciously perceived stimuli or by reflexive unconscious response. In either case, activation stimulates sympathetic thoracolumbar spinal ganglia to release norepinephrine (NE) and neuro-peptide Y directly onto receptors in the heart, lungs and arterioles. This results in an increase in heart rate, blood pressure and cardiac output. The bronchi dilate allowing increased airflow. Perfusion of vascular beds in muscles increases. The pupils dilate allowing a better visual response. The animal becomes more alert and focused. The adrenal glands release the catecholamines epinephrine (EPI) and NE into the circulation, which sustains these effects. Glycogen that has been stored in the liver and muscles is metabolized to glucose providing immediate energy availability. This response evolved to allow organisms to escape from physical threats. Although much of modern stress is psychological rather than physical (deadlines, red lights) the physiological response is the same. The HPA also responds to stressors. In response to stimuli perceived as stressful, the hypothalamus releases arginine vasopressin (AVP) and corticotropin releasing factor (CRF) from the peri-ventricular nuclei to the anterior pituitary. The anterior pituitary releases adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to release cortisol and aldosterone. Cortisol mobilizes glucose and increases gluconeogenesis. Aldosterone and AVP causes the kidney to retain salt and water, thus increasing blood pressure and circulating volume. Both the SNS and HPA axis are self-balancing. For example, cortisol and aldosterone act on receptors in the hippocampus, amygdala and hypothalamus to reduce the release of CRF. This keeps the activation of HPA from becoming too high or persisting too long. Natural selection has favored the development of these “prepare and repair” systems to respond to acute threat or actual injury. When the threat has passed, homeostasis is restored. However, if a stressor is chronic and the activation of these systems persists, these same responses can be pathological.


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If we look at the stress response in more detail, we find beneficial effects (+) of acute activation but adverse effects (−) of chronic activation:

r

Cortisol reduces insulin release, insulin-dependent growth factor (IGDF) and insulin sensitivity: + −

r

Cortisol and norepinephrine increase inflammatory cytokines such as interleukin6 (IL-6) and tissue necrosis factor alpha (TNF-a) and the acute phase reactant C-reactive protein (CRP): + −

r

Acutely provides immediate energy Chronically contributes to development of diabetes mellitus, obesity and dyslipidemia

−

Acutely activate cellular immunity to fight acute infection Chronically cause inflammation in the arterial endothelium contributing to the development of atherosclerotic plaques, a risk factor for CAD Chronically stimulate CRF release, perpetuating the stress response

Norepinephrine and AVP constrict renal arterioles and promote sodium retention: + −

Preserves circulating volume and reduces the risk of hypovolemic shock in acute injury or bleeding Contributes to the development of hypertension

Psychosocial stressors activate the stress response through both the SNS and HPA axis. The hormonal and immunologic responses to psychological stress can affect the onset and course of a variety of conditions including

r r r r r

Diabetes mellitus Hypertension Inflammatory bowel disease Asthma Multiple sclerosis

In controlled experiments, it is possible to measure and reproduce the physiological responses to acute psychological stress. A group of volunteers is exposed to standardized triggers such as public speaking, mental arithmetic under time pressure or viewing frightening movies or photographs. Their physiological responses are compared to a control group with no exposures. The comparison reveals differences in hormonal secretion and the effects on pulse, blood pressure and blood glucose between the two groups. Understanding the effects of chronic psychosocial stressors is more difficult because of multiple confounding variables. Some stressors such as death of a spouse or child, divorce or loss of employment are either present or absent. Other stressors such as job dissatisfaction or low social support have a range of severity. The duration of exposure to the stressor may also be difficult to measure. There may be multiple psychosocial stressors present in the study groups. It is intuitive that if one stressor is bad, two or more stressors are worse. The Recent Life Change

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Questionnaire (RLCQ) developed by Holmes and Rahe is a widely used method that demonstrates temporal relationships between stressful events and illnesses and quantifies the additive effects of stress. Chronic physiologic changes are also found with prolonged emotional or social stressors. For instance, working women with children have higher levels of NE than working women with no children. The risk for working mothers developing CAD increases linearly with the increased number of children. Work stress is characterized as high-demand work with low autonomy and low self-reported satisfaction. In one study, workers with this profile had higher than normal levels of fibrinogen, which can trigger clot formation in coronary arteries leading to MI. Negative emotions of depression, anxiety or hostility are associated with increased health risk. The inflammatory cytokine IL-6 and the acute phase reactant CRP are both persistently elevated in patients who exhibit these negative emotions prominently. Lower socio-economic status (SES) is associated with higher risk and poorer outcome of CAD, DM, HTN and asthma. However, lower SES is also associated with many health-risk behaviors (smoking, alcohol or unhealthy diets). Low social support, divorce and low job satisfaction may be risk factors for low SES or may result from low SES.

Case Vignette 11.1.4 Continuation Mr. Rosenthal is admitted to the intensive care unit and, after appropriate testing, undergoes coronary artery by-pass graft surgery. His hospital recovery is uncomplicated. You complete your psychiatry clerkship and have started your first rotation in the internal medicine clinic. By chance, he is scheduled for a follow-up visit with you. He has been participating in a cardiac rehabilitation program that includes dietary advice, smoking cessation education and progressive exercise. He tells you that he has not any of the symptoms that brought him to the ER. He doesn’t have any pain. He feels that the cardiac rehabilitation program was initially good and he was feeling that his stamina had been increasing. For the last 2 weeks, however, he has lost interest in attending the program and has become pessimistic about returning to work. He has had difficulty sleeping. He looks sad. He has a large cold sore on his lip. He tells you in a slow, monotone voice, “I don’t think it’s worth it.”

Please proceed with the problem-based approach! Mr. Rosenthal’s follow-up history suggests major depressive disorder, which is described in Chap. 22. In this chapter, we will continue our focus on the stress responses and its relation to depression, CAD morbidity and mortality and effects on the immune system.


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Major depressive disorder and sub-clinical depression are part of a vicious cycle. Psychosocial stress activates the stress response, which may lead to depression. Depression has been shown to increase the risk of developing CAD and MI and to occur frequently in the post-MI period. Depression worsens the functional outcomes of patients who survive MI, e.g., return to work, satisfaction with relationships, overall sense of well-being and greater non-cardiac health concerns. These poor functional outcomes result in increased psychosocial stress. As described above, stress activates pro-inflammatory cytokines, IL-6, TNFalpha and CRP. The inflammatory response is necessary to fight infection and to repair damaged tissue. Inflammatory cytokines also cause behavioral changes that benefit healing and recovery. In animals, there is decreased motor activity, decreased novelty-seeking and decreased pursuit of reward. The same behaviors are seen in humans who give subjective explanations for these behaviors: fatigue, loss of motivation and loss of ability to experience pleasure (anhedonia). IL-6 activation in the CNS affects metabolism of serotonin, dopamine and norepinephrine in the hippocampus, amygdala and nucleus accumbens, portions of the limbic system that regulate emotion. This “let-down” feeling is beneficial for a short period of recovery, but if it persists may begin the vicious cycle of depression.

Case Vignette 11.1.5 Conclusion During the follow-up visit, you determine that Mr. Rosenthal does not have suicidal ideation. He tells you that he thinks only “weak people” get depressed and that he has always been able to control his life before his MI. You discuss with him that depression is frequent after an MI and you provide a brief explanation about stress and health. Together you develop a treatment plan.

Please proceed with the problem-based approach! Primary care physicians treat the majority of patients with depression. Your treatment plan might include a prescription for an antidepressant medication. Although the primary mechanism of action for the antidepressant effects is in the brain, some antidepressants have caused reductions of pro-inflammatory cytokines in humans and in laboratory animals. It is important to pay attention to Mr. Rosenthal’s coping strengths (please also refer to Chap. 6). Optimists expect that negative events are isolated occurrences that will eventually resolve and that these events could happen to anybody. Pessimists believe they are victims of repeated patterns of negative events that will persist and can be blamed on themselves or others. In a group of initially healthy men, those with optimistic interpretations of life events had half the number of MIs or

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M.K. Daines, N. Majumdar Table 11.1 Stress management techniques Exercise Social support Diversion Relaxation Time management Diet Sleep

Aerobic, outdoor may be best Family, friends, colleagues Sports, movies, artistic activities Music, reading, yoga Using planning tools Avoid excessive caffeine, alcohol 7 or more hours a night

cardiac deaths than pessimists. Optimism improves immune measures and reduces the intensity and duration of the stress response. Although optimistic and pessimistic dispositions are usually well-established traits by adulthood, it has been shown that people can learn to adopt an optimistic style. Psychological treatments that help patients to learn more optimistic thought patterns are known as cognitive behavioral therapies (CBT). Individuals with positive coping strengths are less likely to engage in health-risk behaviors such as smoking or substance abuse and more likely to adhere to prescribed treatments of medication, diet and exercise. Humor and laughter are positive coping responses that have been shown to cause an immediate beneficial immune response in patients with rheumatoid arthritis and in healthy volunteers. Stress management techniques can pro-actively allow for improvements in stress and coping before a medical problem occurs. Table 11.1 offers a summary of commonly employed stress management approaches. People with higher levels of social support appear to have more robust immune systems. Aerobic exercise programs may be as effective as antidepressant medications in some groups of depressed patients. Lifestyle changes can lead to dramatic improvements in well-being.

Conclusions Psychosocial stressors activate physiologic responses in the autonomic nervous system, the hypophyseal-pituitary-adrenal hormonal system, the immune system and the clotting system to respond to stressors. These systems return to baseline levels when the stress has resolved. Extreme, cumulative or prolonged stressors can result in an excessive or prolonged stress response that may initiate, precipitate or perpetuate many serious illnesses. Patients can learn effective coping methods to improve health.

Review Questions 1. Stress responses are . . . (a) Always beneficial (b) Often beneficial chronically


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(c) Often beneficial acutely (d) Without benefit 2. Which of these is not an effect of chronic norepinephrine elevation? (a) (b) (c) (d)

Preservation of circulating volume and decreased risk of hypovolemic shock Chronic corticotropin releasing factor release Increased likelihood of developing hypertension Increased likelihood of developing atherosclerotic plaques, a risk factor for CAD

3. Which of these is considered a safe antidepressant for a cardiac patient? (a) (b) (c) (d)

A tricyclic antidepressant A monoamine oxidase inhibitor A selective serotonin uptake inhibitor None of the above

4. How is coping strength related to cardiac disease? (a) Optimists have more heart attacks and cardiac deaths than pessimists. (b) Optimists have fewer heart attacks and cardiac deaths than pessimists. (c) Pessimists and optimists have equal numbers of heart attacks and cardiac deaths.

Answers 1. c, 2. a, 3. c, 4. b

Bibliography Holmes SD, Krantz DS, Rogers H, Gottdiener J, Contrada RJ. Mental stress and coronary artery disease: A multidisciplinary guide. Progress in Cardiovascular Disease, 2006; 49: 106–122. Rahe RH, Veach TL, Tolles RL, Murakami K. The stress and coping inventory: An educational and research instrument. Stress Medicine, 2000; 16: 199–208. Raison CL, Capuron L, Miller AH. Cytokines sing the blues: Inflammation and the pathogenesis of depression. Trends in Immunology, 2006; 27: 24–31. VanItallie TB. Stress: A risk factor for serious illness. Metabolism, 2002; 51: 40–45.

Chapter 12

Health Care 101 David C. Fiore and Jason P. Crawford

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr.

This chapter will give you an opportunity to explore some of the more interesting and important facets of the rapidly changing landscape of health care delivery. The cases highlight how Americans obtain and pay for their health care, how health care is financed, why the “system” is structured the way it is, and how “public health” fits into the system. We hope you’ll be able to formulate your own opinions in regards to the relative advantages and disadvantages of health care delivery in the United States and how you believe health care may, or should, be delivered 5 or 10 years from today. At the end of this chapter, the reader should be able to 1. Discuss the current organization, structure, and financing of the health care system in the United States 2. Articulate key strengths and weaknesses of our current health care system, including issues of quality, access, and cost 3. Describe the importance of “public health” and how public health differs from, yet complements, individual health care As in the other chapters in this book, we will be using case vignettes as the vehicle for delving into these topics; but first, we would like to introduce the Baker family and provide some introductory information that will allow the reader to understand the health insurance situations that arise in the scenarios. Please note that this chapter modifies the PBL tables in order to best address the complex topic of health care financing. Mrs. Betty Baker: a 54-year-old graphic artist for Can-do advertising company who moved to the United States from Ottawa, Canada, when she was 28. Mr. Bob Baker: a 62-year-old human resources administrator for a mid-sized auto parts company who was born and raised outside of Detroit, Michigan. Mr. Brian Baker: a 19-year-old sophomore college student, son to Betty and Bob, currently an undeclared major, enjoying his early college years. D.C. Fiore Associate Professor, Family and Community Medicine, University of Nevada School of Medicine


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Ms. Bridget Baker-McGladrey: the 22-year-old daughter of Betty and Bob who is a healthy married woman who has completed 2 years of college but recently put it “on hold” when she became pregnant 6 months ago and decided to drop out to work at a local department store to save for her child’s future. Mr. Tom McGladrey: a 25-year-old male computer technician. He is employed in a “start-up” business of five employees. He is “buying in on the ground floor” by sweat equity, and the company has yet to show a profit. He’s working at a fast-food restaurant part-time to supplement his meager income now that Bridget is pregnant. He has no current major medical issues. Based on the character information above and your knowledge of health insurance options in the United States (see also Tables 12.1a and 12.1b), please fill in the below table and consider the potential sources of health insurance coverage each character may have out of the following list: Self-pay (meaning “uninsured”) Private individual insurance Employer-sponsored insurance Medicaid Medicare State Children’s Health Insurance Plan (S-CHIP) CHAMPUS Veterans Affairs Canadian Health Act provincial insurance

Case Vignette 12.1.1 Presenting Situation: Betty Baker During her annual physical, Betty Baker’s primary care physician, Dr. Dulces, noticed a lump in her right breast and the mammogram confirmed a “suspicious lesion.” Dr. Dulces referred Betty to the surgeon, Dr. Sherman, who confirms cancer with a biopsy and later performs a partial mastectomy. Dr. Dulces then refers Betty to Dr. Sung, a renowned oncologist, for chemotherapy. Unfortunately, Dr. Sung is not on Betty’s employer-sponsored health maintenance organization (HMO) health insurance plan’s list of contracted providers. So, she returns to Dr. Dulces, who now refers her instead to Dr. Walsh, who is indeed on her HMO plan’s provider list. Due to the stage and grade of her cancer, Dr. Walsh recommends initiation on a novel chemotherapy regimen only available through the University Hospital’s Cancer Center. Betty discusses this with Dr. Dulces, who makes it clear that this is out of her area of expertise, but supports Betty’s decision to opt for this treatment, even though the University Hospital is approximately 2 hours away. Unfortunately, she finds out that her HMO plan has refused coverage of the treatment as it is pending FDA approval and is still classified as “experimental” by the plan. After many calls to her insurance provider (and with much assistance from Dr. Dulces, who had tried to hide her frustration with the insurance company), Betty is “approved” for a consultation at the University, but no guarantee is made that the insurance company will pay for the treatment.

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Table 12.1 Demographic information and potential health insurance coverage a. Contents to be filled in by students Person

Age

Employment status

Potential source of coverage

What else you need to know

Employer-sponsored (hers Size of the companies, what or husband’s), self-pay insurance plan they offer, how long she’s been there Employer-sponsored, As above, more about his injury self-pay and coverage rules at the VA Private individual Student health plan availability insurance, and coverage, parental employer-sponsored coverage of college-enrolled (mother’s or father’s), kids self-pay Medicaid or S-CHIP, Income level, Medicaid self-pay requirements (especially concerning pregnancy) self-pay, possibly on Ability to cover adult children parent’s insurance on parental plan Canadian Health Availability of private Insurance, private, insurance in Canada, self-pay coverage while in United States Medicare, VA, Medicaid, Medicare coverage, VA self-pay

Betty Baker Bob Baker Brian Baker Bridget Baker – McGladrey Tom McGladrey b. Populated table Betty Baker

54

Employed

Bob Baker

58

Employed

Brian Baker

19

Unemployed student

Bridget 21 BakerMcGladrey Tom 23 McGladrey Kelly Zanjen 79

Unemployed

Retired

Blake Baker

Retired

85

Employed

At her first visit in the University Oncology Center she meets other women with breast cancer and is startled to learn that some women were “approved” for treatment without any difficulty while others, like herself, have been stopped at almost every step. In addition to learning all she can about breast cancer, Betty is determined to learn more about the health care system: Why is she being “bounced around” from doctor to doctor? Why do some women have no problem getting their insurance company to pay for the University’s Oncology Center treatment? Why is certain therapy only offered at major “centers” like the University?


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Table 12.2 Betty Baker

What are the facts?




Betty’s medical condition What are Betty’s options to receive care? How has the health care system impacted Betty’s options? What options are available to Betty?

Complete Table 12.2. Like so many other Americans, Betty is confused by the complex nature of the US health care system’s organization. The role of any health care system is to assure that the “right patient receives the right service at the right time and in the right place” (Bodenheimer, 2005; Rodwin, Kervasdoue and Kimberly, 1984). In order to accomplish this role, a number of organizational models evolved to provide defined levels of care within a health care system. In 1920, Lord Dawson published a report defining these levels of care: (1) primary care constitutes the overwhelming majority of health care encounters and refers to provision of preventive care and treatment of common health problems; (2) secondary care emphasizes specialty expertise and hospital-based services; and (3) tertiary care focuses on special investigation, treatment, and management of rare and complex diseases and disorders. (4) The term quaternary care has also more recently been coined to delineate highly advanced specialized care that is not widely available or used.

Overview of Health Insurance and Financing in the United States The inevitability of illness throughout our lifetimes mandates the need for health care. The escalating costs of medical care outstrip other areas of the economy and make it difficult for most societies to finance health care. In an attempt to manage costs, the United States has tailored financing systems to fund health care. An essential component of most health care financing schemes is the availability of “health insurance” to provide a source of payment to providers of health care services. The use of health insurance allows the insured a partial shield against the high costs of health care while simultaneously providing funds to subsidize the health care costs of the actively ill. According to Bodenheimer (2005), health insurance allows the distribution of health care “more in accordance with human

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need rather than exclusively on the basis of ability to pay . . . funds are redistributed from the healthy to the sick, a subsidy that helps pay the costs of those unable to purchase services on their own.” Although the majority of health care financing and health insurance coverage worldwide rely heavily on public funding from governmental sources, the United States remains unique in its use of private funding for health care. According to 2006 US Census Bureau reporting, approximately 59.7 % of all non-elderly (less than 65) insured Americans are covered through employer-sponsored insurance, and privately funded employer-sponsored health insurance remains the dominant mode of our health insurance coverage (Denavas-Wait et al., 2007; Clemans-Cope et al., 2006). The private health insurance model began in the 1930s. As health care costs quickly outstripped income potentials for the average US worker, health insurance allowed public access to the array of rapidly developing health care technologies and services. The private health insurance industry in the United States met even greater demand during World War II. The US wartime economy placed significant constraints on both workforce availability and salary increases, so non-salary-based “fringe” benefits became important for recruiting prospective employees. Health insurance coverage plans became very attractive to employees due to escalating health care costs. Federal government tax subsidies (equaling over $100 billion per year currently) provided significant tax shelter for employers and today are one of the cornerstones to the intimate link between employment status and health insurance coverage in the United States (Bodenheimer, 2005). Significant gaps in health insurance coverage for the US population result from the reliance on private employer-sponsored health insurance plans. Those who cannot obtain employment, or who are employed by a business that does not offer health insurance, remained uninsured. The elderly, the permanently disabled, the poor, and children emerged as uninsured populations in the late 1950s (Bodenheimer, 2005). The reaction to this uninsured population gap was the advent of Medicaid and Medicare, governmentally funded health insurance programs. As of 2006, these programs constitute 27.0 % of all health insurance coverage for the US population (Denavas-Wait et al., 2007). Medicare was enacted in 1965 in order to provide partial health insurance coverage for all persons 65 years or older and persons with permanent disabilities. The Medicaid program was developed to provide partial coverage for the poor, some persons with disabilities, children, pregnant women in need, and select elderly who also qualify for Medicare (the “dual eligible”). The State Children’s Health Insurance Plan (S-CHIP) was enacted in 1997 to provide expanded coverage for children and adolescents below the 200 % federal poverty level (FPL). The military and Veterans Health Administration provide federally funded health insurance for the active, retired, and veteran populations of the US Armed Forces through programs such as the Comprehensive Health and Medical Plan for Uniformed Services (CHAMPUS), the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), and the Department of Veterans Affairs (VA). The VA system provides medical services to low-income veterans and those with permanent disabilities and is funded annually at the discretion of Congress.

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The simplest models for health care delivery can be organized into two main subsets, the regionalized model and the dispersed model. The regionalized model emphasizes a strong base of primary care provision for all localities throughout the service area. Secondary and tertiary care is provided at more distinct district or regional locations, such as large urban centers, and services much larger subsets of the overall population within the health system. Access to higher levels of care originates at the primary care level. An example of this model is the English National Health Service (described in more detail later; Bodenheimer, 2005). The dispersed model of care places emphasis on provision of all levels of care throughout all localities of a service area. Though dispersed care models may intuitively seem the most advantageous to a population, the costs of health care delivery under this model are often prohibitive. The high cost of health care delivery and organization prompted efforts to control the escalating costs of health care during the 1960s and 1970s. Betty’s feelings of frustration and confusion regarding her own health care access and delivery stem from the development of such cost-containment strategies. The advent of the health maintenance organization (HMO) under the Nixon administration’s HMO Act of 1973 and the managed care movement in the 1980s and 1990s had significant impact on the provision of health care within the United States. Unlike indemnity plans that offer reimbursement of health care expenses on a fee-for-service basis, HMOs and other types of managed care organizations (MCOs) use systems and techniques to control the use (and, ostensibly, the cost) of health care services (Ruth, 2005b). The ultimate goal of a managed care organization (MCO) is providing health care services to a defined population in a cost-efficient manner while maintaining the population’s health. Several forms of MCOs have developed over the last few decades. The most well known is the HMO. Members pay a fixed fee to access the HMO’s network of contracted providers (who provide services to members at a discounted rate under contract with the HMO) to meet the member’s health care needs. A primary care physician (PCP) provides preventive and routine health services as well as coordinates referrals for specialty care and advanced diagnostics and treatments. The emphasis for PCP is on prevention of disease, and medical care is generally directed by a set of approved guidelines within the HMO. Health maintenance organizations can be further subdivided into a variety of models depending on how providers are contracted. An Individual Practice Association (IPA) is a group of independent providers who join together to contract with an HMO. In a staff model HMO, such as Kaiser Permanente, the HMO employs all providers and owns its own hospitals, clinics, and labs to provide services exclusively for HMO members. A group model HMO contracts with a single multispecialty group to provide services to members. In a network model HMO, the HMO contracts with a combination of groups, IPAs, and individual physicians (Baldor [1998]). Two additional MCO models have developed during the 1990s to provide greater flexibility to their members. First, a Point of Service (POS) plan allows members to see providers outside of the contracted network but at a higher out-of-pocket

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expense to the member. Second, a Preferred Provider Organization (PPO) plan designates some providers as “preferred” and sets lower deductibles and co-payments for these physicians while still allowing members the option to use out-of-network physicians at higher out-of-pocket costs. Both POS and PPO plans differ from HMOs in that traditional HMO plans will not cover any of the costs for services of an out-of-network provider. In Betty’s case, her employer has contracted with an HMO that is restrictive to who can provide her services (i.e., the oncologists) and what services can be provided to her.

Health Care Costs Overview Case Vignette 12.1.2 Conclusion Through her research, Betty has learned that the innovations of health care in the past 30 years have vastly improved the prognosis for breast cancer. Depending on the stage of the cancer, 5-year survival ranges are over 50 %. Unfortunately, these advances did not come without a cost. After reviewing some the bills related to her treatment, Betty wonders why the provision of health care is so expensive and where all of that insurance money goes to anyway. She simply cannot imagine how anyone could pay “out of pocket” for these huge bills. Betty concludes that the health care costs in the United States are spiraling out of control. Her oncologist prescribes a long-term medication for her breast cancer and she is cancer-free at 3-year follow-up.

Please proceed with the problem-based approach! Please complete Table 12.3. Betty is correct—the costs of health care in the United States are astronomical. National health expenditures rose at twice the rate of inflation from 2004 to 2005 reaching roughly $2 trillion. This accounts for 16 % of the gross domestic product (GDP) (Centers for Medicare and Medicaid Services (CMS), 2007b; National Coalition on Health Care (NCHC), 2007a; Organization for Economic and Co-operation Development (OECD), 2007). In other words, $1 of every $6 spent on US-made goods and services went to health care! US per capita spending on health care has reached an unprecedented high worldwide of $6,700 (CMS, 2007b; NCHC, 2007a). The next closest countries to the US for expenditures on health care are Switzerland at 11.6 % of its GDP and Norway at $4,364 per capita (OECD, 2007). Unfortunately the health care costs in the United States continue to skyrocket. According to the Milliman Medical Index (MMI),

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Table 12.3 Betty Baker What are the facts?

What do you What are your want to know hypotheses? next?


What are health care costs in the United States? Who pays this cost (individual, employers, government)? Where does the money go?

the total costs of medical spending for a family of four in 2007 is estimated to be $14,500, an increase of 8.4 % over the 2006 MMI (Milliman Medical Index (MMI), 2007). Where do these costs arise? At roughly 82 % of all health care cost, hospital and physician services account for the greatest majority of spending. Outpatient and inpatient hospital services increases at the most rapid rate of 9.0 and 9.8 %, respectively (MMI, 2007). How does this impact out-of-pocket expenditures? The MMI estimates that the average family will spend $2,420 in out-of-pocket expenses through health insurance plan cost-sharing at the time of service (i.e., deductibles, co-payments), an increase of $210 over 2006 data (MMI, 2007). In addition, for the $14,500 annual premium for an insurance plan, the employee contributes 38 % ($3,171) via payroll deductions, while the employer contributes the remaining 62 % ($8,909). In combination, payroll deductions and out-of-pocket cost-sharing payments total $5,591 paid by the employee, an increase of over 100 % since 2000 (NCHC, 2007b).

Case Vignette 12.2.1 Presenting Situation: Bob Baker After many years of uncontrolled hypertension, cigarette smoking, and hyperlipidemia, Bob suffered a large right-sided cerebrovascular accident 6 months ago. After an inpatient hospital stay, Bob spent 8 weeks at a rehabilitation center in order to adapt to the problems he had with moving his left arm and leg. He was unable to maintain his human resources position at the auto parts company and was forced into retirement due to disability. Bob purchased continuation coverage through his employer’s Consolidated Omnibus Budget Reconciliation Act, or COBRA plan. He is increasingly concerned with expenses since his wife’s diagnosis of breast cancer, since his COBRA plan’s monthly premiums are significant. He is unsure whether he and his wife will be able to afford the premiums for the COBRA plans which now cover both of them and he wonders what alternatives he has. During one of his visits to Dr. Dulces, she informs him that he may qualify for Medicare due to his disability.

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He replies that he thought Medicare was just for “old folks.” He decides to explore this option in more detail on the Internet and effortlessly finds medicare.gov.

Please proceed with the problem-based approach! Please complete Table 12.4. Medicare was developed as a tax-financed insurance program for all people aged 65 and older. It subsequently expanded to include people under 65 with permanent disabilities. The program is currently administered by the Centers for Medicare and Medicaid Services (CMS, http://www.cms.hhs.gov/), formerly known as the Health Care Financing Administration (HCFA), under the supervision of the Department of Health and Human Services (DHHS, http://www.hhs.gov/). At age 65, a person is automatically enrolled in Medicare if he/she is eligible for Social Security (meaning the person or their spouse has paid into the Social Security System for 10 years) regardless of current income, retirement status, or medical history. A person under 65 with a permanent disability is eligible for Medicare coverage after receiving Social Security disability benefits for 24 months, though persons with chronic kidney disease often have the 2-year waiting period waived (Bodenheimer, 2005; Henry J. Kaiser Family Foundation (KFF, 2006b). As of 2006, Medicare provides coverage for 13.6 % of all insured Americans, equating to nearly 43 million persons (Denavas-Wait et al., 2007; KFF, 2006b). In 2006, total Medicare benefit spending equaled $342 billion, accounting for 14 % of the federal budget (CMS, 2007b; KFF, 2006b). Medicare is subdivided into four parts. Medicare Part A provides payment for inpatient hospital, skilled nursing facility, home health, and hospice care. Medicare Part B, the Supplementary Medical Insurance Trust Fund, pays for physician services, both outpatient and preventive, and some medical equipment and home health costs and requires beneficiary premiums. This standard monthly premium for 2007

Table 12.4 Bob Baker What are the facts? Who does Medicare cover? About what Medicare covers How is Medicare financed? What are the challenges Medicare is facing?



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equaled $93.50 but may be as high as $161.40 depending on household income levels (CMS, 2007b). Medicare Part C, or the Medicare Advantage program, allows managed care companies to administer Medicare benefits. Medicare Part D, begun in 2006, provides a partial outpatient prescription drug benefit to beneficiaries. It requires a beneficiary premium of about $25 per month. Medicare is by no means a comprehensive health insurance program. In general, Medicare covers only 45 % of total health care costs for beneficiaries due to cost-sharing measures such as annual deductibles, monthly premiums, and coverage exemptions that require out-of-pocket spending for the beneficiary. Therefore, many Medicare recipients purchase supplemental private health insurance coverage, known as “Medigap,” to lower annual out-of-pocket expenses (KFF, 2006b; Ruth, 2005a). Additionally, over 7 million Medicare beneficiaries are dually eligible for state-based Medicaid coverages to help fund their Medicare premiums, deductibles, and non-Medicare-covered health expenses such as long-term care services (KFF, 2006b). As the US population ages, and with a decline in the ratio of workers to beneficiaries, Medicare currently faces a “funding warning.” As Medicare spending increases to meet the health care needs of the aging “baby boomer” generation, the Medicare Part A Trust Fund reserves are projected to be exhausted by 2018 (KFF, 2006b). The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1996 requires that employers with 20 or more employees offer employees and their families a temporary extension of health coverage (known as “continuation coverage”) under their sponsored health plan when coverage under the plan would otherwise end. COBRA may be purchased at the time of voluntary or involuntary termination, reduction in work hours (thereby disqualifying employee for benefits), divorce or separation from covered employee, or death of covered employee. In general, COBRA plans provide no employer sponsorship of the premium payments, therefore the employee bears the entire cost for coverage.

Case Vignette 12.3.1 Presenting Situation: Bridget McGladrey Bridget and Tom began their relationship about 2 years ago. They recently learned that she was about 12 weeks pregnant and quickly had the wedding they had been planning for the following summer. Bridget dropped out of college last year and has been working at a local department store that offers health insurance benefits only after employment for 6 months. She is currently uninsured. Money has been “tight” considering Tom’s business has only just opened and his income has been very low. Bridget is very concerned about how she can afford prenatal care for her pregnancy and care for the new baby. She has been contemplating her options and was told by a friend at work that she may qualify for the state-based Medicaid program. She is unfamiliar with Medicaid and gets on the Internet to find out if she will qualify.

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Please complete Table 12.5. The Medicaid program serves as the nation’s major public health insurance program for low-income people. Medicaid, unlike Medicare, is a state-based program funded jointly by the state and federal governments. Like Medicare, CMS provides federal supervision over Medicaid programs. The federal government creates minimum eligibility guidelines and allows the state authority to optionally extend Medicaid eligibility beyond these minimums. To be eligible for Medicaid coverage, a person must meet financial criteria and fall within one of three eligibility groups: categorically needy, medically needy, and special groups (CMS, 2005). These groups include children and newborns, pregnant women, people with disabilities, certain subpopulations with specific medical conditions, low-income workers, and dual eligible Medicare beneficiaries. As of 2006, 12.9 % (45.7 million) of all insured Americans received benefits through state-based Medicaid programs (Denavas-Wait et al., 2007; CMS, 2006). Medicaid services vary by the state. Federally mandated coverages include the inpatient and outpatient hospital treatment, professional services (physicians, dentists, midwifes, and nurse practitioners), laboratory and x-ray, nursing home and home health care for those 21 and older, family planning, pregnancy-related, wellnewborn, and well-child care, and rural health clinic/federally qualified health center services. Optional services determined by state authority include prescription drugs, clinic services, prosthetic devices, hearing aids, intermediate care facilities, and other elder services. Medicaid remains the major source of coverage for low-income individuals who need mental health services and substance abuse treatment and is accountable for

Table 12.5 Bridget and Tom What are the facts? What are the origins of the Medicaid program? How is Medicaid funded? Who does Medicaid cover? What does Medicaid cover?



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44 % of public mental health spending (Substance Abuse and Mental Health Services Administration (SAMHSA), 2005). Medicaid spending accounts for, on average, 22 % of state budgets (CMS, 2007b; NCHC, 2007b). This places Medicaid spending second only to education as the states’ highest governmental expense. On average, the federal government finances 57 % of all Medicaid programs (KFF, 2006a). The largest proportion of expenditures is attributable to the dual eligible elderly and disabled, accounting for 70 % of Medicaid spending. Medicaid payments for nursing home care, a service not covered by Medicare, remains the most costly at 44 % of all expenditures (KFF, 2006a).

Case Vignette 12.3.2 Continuation Bridget has completed 6 months of employment at the department store, but has had to reduce her time to 20 hours per week, so she still does not qualify for health insurance. Her prenatal care is covered by Medicaid, but she had to call many doctors to find one who would accept her insurance. Bridget wonders if Medicaid will still cover her and little Tommy once he’s born, if they qualify for her employersponsored insurance. Her friend at work told her the insurance plan “stinks” and Bridget is unsure about how to proceed.

Please proceed with the problem-based approach! Complete Table 12.6. A third governmental-sponsored program, the State Children’s Health Insurance Plan (S-CHIP) aims to address the growing problem of uninsured children nationwide by increasing coverage for children less than 19 years whose family income Table 12.6 Bridget and Tom What are the facts? What are Bridget’s options? How does the government provide care to children? What are employer-sponsored insurance opportunities for part-time workers?



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is below 200 % of the federal poverty level (FPL) (set at $41,300 for a family of four in 2007) (CMS, 2007a). This group is referred to as “targeted low-income children” and is comprised of children whose families earn too much to be eligible for Medicaid but not enough to purchase private insurance. Enrollees in the state-based S-CHIP programs cannot be eligible for Medicaid or private insurance (Ruth, 2005b). Like Medicaid, S-CHIP provides federally mandated minimums. Within these federal guidelines, each state can design a program of eligibility, enrollment, payment, benefits, and operation/administration. The coverage must include those stipulated by the federal guidelines for Medicaid, specifically targeting wellnewborn/well-child care, immunizations, and emergency services. The federal and state governments, similar to Medicaid, jointly fund the S-CHIP programs. The federal government allocates funds to each state via an annual capped block grant that matches (up to 85 % of) the respective state’s annual contribution to the program. The total federal and state S-CHIP expenditures for 2006 were $5.4 billion and $2.4 billion, respectively, for a total governmental expenditure of $7.8 billion (Center for Children and Families, 2007; KFF, 2007a). Continued federal support for S-CHIP will be voted on by Congress during the 2007–2008 session.

Case Vignette 12.3.3 Continuation Since Bridget spends a lot of time in the waiting room at the Maternity Clinic she has made friends with some of the other women there. Her best new friend, Juanita Juarez, shocked Bridget with stories of how much difficulty her family (some of whom are undocumented immigrants) has in getting health care. Juanita claims her niece died of pneumonia because she could not see a doctor soon enough and her parents were too afraid of deportation to go to the ER. When Bridget shares this with Tom, he scoffs that this could not be true in the United States, because everyone, regardless of insurance status, can go to the ER anytime they want for “free” care.


Complete Table 12.7. The US Census Bureau indicates a steady rise in the uninsured US population over the last decade. According to 2006 data one in six Americans lack coverage (Denavas-Wait et al., 2007). In addition to the uninsured population, an estimated additional 30–40 million are considered “underinsured” due to coverage restrictions, financial barriers, and/or lack of access to care (Bodenheimer, 2005).

What are some recent proposals to address this problem?

What are some medical and financial consequences of being uninsured?

Why are they uninsured?

Who are the Uninsured?

How many Americans are uninsured?

What are the facts about access to health care and the uninsured? What are your hypotheses?

Table 12.7 Health Access What do you want to know next?


164 D.C. Fiore, J.P. Crawford

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Who are the uninsured? Currently 80 % of uninsured Americans come from low-income working families—70 % with one or more full-time workers and 11 % with part-time workers (Denavas-Wait et al., 2007; KFF, 2006c). The elderly and children have more access to health care coverage via the Medicare, Medicaid, and/or S-CHIP programs, leaving non-elderly adults to constitute 80 % of the uninsured population. Eighty percent of the uninsured are native or naturalized US citizens, although non-citizens have a higher population uninsured rate (40–50 %) compared to the US average due to income and eligibility factors (KFF, 2006c; KFF, 2007b). Uninsured rates vary by racial/ethnic group and are presented in decreasing order: Hispanics (34.1 %), American Indian/Alaskan Native (29.9 %), Native Hawaiian/other Pacific Islanders (21.8 %), Black (20.5 %), Asian (15.5 %), and White (14.9 %) (KFF, 2006c; KFF, 2007b). The largest concentrations of the uninsured are found in the South (19.0 %) and the West (17.9 %). California, Texas, Florida, and New York represent the states with the highest percentage of uninsured population (Denavas-Wait et al., 2007). Why are the uninsured uninsured? Contrary to popular belief, only 7 % of those who are uninsured state that they “do not need health insurance” (KFF, 2006c). Most of the uninsured (53.3 %) cited “cost” as the number one reason for their lack of health insurance (Centers for Disease Control and Prevention (CDC), 2006). With insurance premiums increasing by 143 % since 2000 compared to a mere 20 % increase in wages over the same time period, low-income working families are no longer able to afford the premium payments. The second and third most common reasons for lack of health insurance are reported to be “lost job or change in employment” (26.9 %) and “employer did not offer or insurance company refused” (14.1 %) (CDC, 2006). Since the economic recession of 2001, employment opportunities have shifted from full-time, high-wage jobs to part-time, low-wage jobs, many of which offer no employer-sponsored insurance plans. Additionally, companies previously offering employer-sponsored plans began to drop coverages or shift more of the premium contributions to employees due to the rapid inflation of insurance premium costs. The poor and near poor are hardest hit by these shifts in employment opportunities and costs, further increasing these populations’ uninsured rates. How does lack of insurance affect the health care for the individual? The uninsured have a much greater probability of not having a regular source of care, with over 20 % (versus 3 % of the insured) reporting emergency rooms as their usual source of care (KFF, 2006c). For uninsured people, the out of pocket costs of health care lead to postponement of needed care and preventive health measures. This leads to delays in diagnoses and presentations at later stages in disease often mandating higher acuity and more expensive care. In fact, in 2004, per capita costs for the uninsured are almost twice as high as the insured (KFF, 2006c). Additionally, lack of financial resources often leads to non-adherence with prescription medications and recommended follow-up. These barriers to health care for the uninsured lead to an estimated 10–15 % reduction in health overall and projected 18,000 potentially preventable deaths per year in the 25 to 64-year-old age group (Institute of Medicine (IOM), 2006).

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Insurance coverage status has a significant impact on mental health as well as physical health. The majority of insurance plans do not provide as comparable coverage for mental health services as medical and surgical benefits. Less than one-half of people with diagnosable mental disorders receive treatment during their lifetime. The Mental Health Parity Act of 1996 was passed in an attempt to close the gap between mental health and medical service coverage by prohibiting insurance companies from paying less for mental health care than for general medical care. Although Medicare and Medicaid provide mental health coverage, significant outof-pocket expenses and coverage gaps lead to a high uninsured/underinsured rate in this population. In the United States, there is no such thing as “free” care for the uninsured; 35 % of all uncompensated care is paid for out-of-pocket by the uninsured (KFF, 2006c). Americans are divided on whether or not health care is a “right.” Approximately 50 % of Americans believe that the government should insure all Americans (Rasmussen Report, 2007). However, others have noted that health care is not a right delineated in the Constitution (unlike access to legal council). Many countries and international bodies do recognize health care as a right (http://www.nesri.org/fact sheets pubs/Right %20to %20Health %20Care.pdf).

Case Vignette 12.4.1 Presenting Situation: Brian Baker Brian has recently returned to school after summer vacation for his sophomore year. Due to the recent financial constraints from his mother and father’s illnesses, at the start of the new college year, they decided not to purchase him the school’s optional student health plan. After a sexual encounter at a fraternity party, Brian develops a greenish penile discharge. He is very concerned but is hesitant to visit the student health clinic due to the anticipated expense of the visit. After an embarrassing disclosure to his roommate regarding his current condition, the roommate recommends that he go to the local public health department’s STD clinic. Brian did not even know there was a public health department or what “public health” is. He calls the student health center to get directions.


Please complete Table 12.8. Defining “public health” as a whole can be an elusive task. In a theoretical sense, public health is the “fulfillment of society’s interest in assuring the conditions in which people can be healthy” (IOM, 1988). Public health focuses on promoting,

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Table 12.8 Brian Baker What are the functions of a Why did this “health department? structure develop?

What specific What do you want to information would you know next? like to learn about?

Questions (what is public health, roles, levels)

protecting, and improving a population’s health status. Public health relies upon a multitude of disciplines from biology and medicine to statistics and epidemiology to achieve these goals. The primary federal agency for public health matters in the United States is the Department of Health and Human Services (DHHS, www.hhs.gov). With a 2007 budget of $698 billion, DHHS represents almost one-quarter of all federal outlays and contains 11 operating divisions. Within DHHS, the US Public Health Service (USPHS) serves as the federal focal point for public health concerns. Eight agencies are found within USPHS: 1. Substance Abuse and Mental Health Services Administration (SAMHSA, http://www.samhsa.gov/)—enhances the quality of substance abuse prevention, addiction treatment, and mental health services in the United States 2. National Institutes of Health (NIH, www.nih.gov)—currently the world’s premier medical research organization 3. Centers for Disease Control and Prevention (CDC, www.cdc.gov)—provides a myriad of disease control and prevention services as well as health statistics and surveillance 4. Food and Drug Administration (FDA, www.fda.gov)—conducts safety and efficacy research of pharmaceuticals, medical devices, biological products 5. Indian Health Service (IHS, www.ihs.gov)—administers health services to American Indians and Alaskan Natives 6. Health Resources and Services Administration (HRSA, www.hrsa.gov)—the nation’s “access” agency to health care for the low income, the uninsured, and community health centers, contains 6 bureaus and 12 offices. 7. Agency for Healthcare Research and Quality (AHRQ, http://www.ahrq.gov/)— evidence-based information on health care outcomes and quality of care, 2007 budget of $319 million 8. Agency for Toxic Substance and Disease Registry (ATSDR, http://www.atsdr.cdc. gov/index.html)—research, education, and prevention efforts regarding hazardous substance exposure The US Public Health Service Commissioned Corps (http://www.usphs.gov/) also resides within DHHS and is led by the Surgeon General, known as “America’s chief health educator” (www.surgeongeneral.gov). Several other federal agencies also provide some public health-related responsibilities for the United States including the Environmental Protection Agency and the Departments of Homeland Security, Education, Agriculture, Defense, Transportation, and Veterans Affairs.

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The US Constitution places the States as the primary fulcrum for protecting the health of their populations and a large amount of responsibility for public health planning, program implementation, health promotion and education, and evaluation occurs at the state level. Though each state (and territory of the United States) contains a state-based public health agency, their organization and mandated responsibilities vary based upon state-specific laws and regulations. Quite often federal statutes mandate the states’ responsibilities for public health, such as the Clean Air Act, Clean Water Act, and the Occupational Safety and Health Act (OSHA). The Association of State and Territorial Health Officials (ASTHO, http://www.astho.org/) reports the following to be largely state health agency responsibilities: women, infants, and children (WIC) program administration; oversight of public health laboratories; maintenance of vital statistics; tobacco prevention and control; food safety; health facility regulation; and environmental health (ASTHO, 2002).

Case Vignette 12.4.2 Conclusion Brian skips his morning classes and finds the Public Health Department. He is evaluated and treated for gonorrhea. The nurse throws a handful of condoms into the bag with the penicillin. Another health department official asks him the name of his sexual partner. He sheepishly replies that he has no idea. As our nation continues to spend more on health care (now exceeding 16 % of GDP) and as we face the aging of the “baby boomer” population it is becoming apparent to even the most optimistic American that our health care system is soon going to reach the breaking point. The Americans have been citing health care as a top priority for them during each election cycle in recent history. The time for action cannot wait much longer, or we will not be improving a challenged system, but rather picking up the pieces of a destroyed system. With the information gained in working through this chapter, it is our hope that the reader will join in the health care policy debate and help shape the future of health care for all of us in the United States.

Review Questions 1. Approximately what percent of non-elderly insured Americans receive their insurance through an employer-sponsored plan? (a) (b) (c) (d)

10 % 30 % 60 % 90 %

2. Approximately what percent of the United States GNP is spent on health care? (a) 6 % (b) 16 %

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(c) 32 % (d) 66 % 3. Approximately how much do Americans spend on health care per capita? (a) (b) (c) (d)

$600 $1,500 $3,600 $6,700

4. Please match the type of insurance coverage with the most appropriate description. (a) Medicare (b) Medicaid (c) Private insurance 1.Federally funded and is designed to cover the elderly and people with certain long-term disabilities 2.Federally and state funded, designed to cover primarily the poor 3.Primarily employer-based, “fee for service,” and “HMO” models exist

Answers 1. c, 2. b, 3. d, 4. a–1, b–2, c–3

References Association of State and Territorial Health Officials. 2002 Salary Survey of State and Territorial Health Officials. 2002. http://www.astho.org/templates/display pub.php?pub id=128. Baldor R. Managed Care Made Simple, 2nd ed. Blackwell. 1998. Bodenheimer TS and K Grumbach. Understanding Health Policy: A Clinical Approach, 4th ed. McGraw-Hill/Appleton & Lange. 2005. Center for Children and Families. Georgetown University Health Policy Institute. Federal SCHIP Expenditures by State, 1998–2007. 2007. http://ccf.georgetown.edu/. Centers for Disease Control and Prevention. QuickStats: “Reasons for No Health Insurance Among Uninsured Person Aged 2

2

>2

4. Paired? Paired

Paired

Unpaired

Unpaired

5. Variances?

Correlation

Paired t

Equal

Unequal

Equal

Unequal

Unpaired t pooled variance

Unpaired t separate variance

Analysis of Variance (ANOVA)

McNemar’s Chi-Square

Pearson Chi-Square

Fig. 15.1 Selecting a statistical test Source: Garb (1996). Understanding medical research: A practitioner’s guide. Boston: Little, Brown. Figure 15-3, p. 184. Note: See supplemental glossary for explanations of statistical tests.

Case Vignette 15.1.2 Conclusion Following considerable thought to her study design options, Melinda selects a case– control study to evaluate the relationship between long-term use of antipsychotic drugs and movement disorders commonly found in Parkinsonism. A randomized clinical trial with case and control groups would be the ideal. However, that option requires a significant amount of time and capital. After receiving permission from the hospital, she conducts 100 chart reviews (retrospective data) of patients with and without the Parkinsonism symptoms. The Pearson correlation was applied to test for an association. The result was 0.7, confirming a reportable and direct relationship. The next step is to apply a randomized controlled trial to determine whether or not a significant causal relationship exists. Melinda noted that this study may provide useful insight into further studies (i.e., experimental) and assist in successfully applying for grants that would provide the funding for a more involved data collection.

Case Vignette 15.2.1 Shyla Sing Shyla Sing is a 12-year-old girl who was brought to the primary care clinic by her mother. Mrs. Sing explains to the medical psychologist and the first-year resident

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who is shadowing that day that though Shyla appears to be physically fine, she is worried about her child’s mental development. Some of Mrs. Sing’s concerns include Shyla’s difficulty in interacting with her peers. Also, Shyla is extremely shy and refuses to separate from her mother.


Case Vignette 15.2.2 Continuation Shyla’s physical examination revealed no abnormalities and suggested that she is a normal 12-year-old girl. Furthermore, the results of standard laboratory tests did not reveal any medical problems. Mrs. Sing explains that for the past 2 years, Shyla has had “erratic behavior.” Examples include simple dialog resulting in major tantrums. Mrs. Sing may ask for a spoon from the kitchen drawer, and Shyla would suddenly start to cry. When Mrs. Sing approaches her, Shyla would often yell out, “Get away from me. You do not care whether I live or die!” At times, she would escalate the situation by throwing utensils and/or hitting her mother. This type of behavior usually occurs when she is alone with her mother. Furthermore, Shyla’s academic performance has shown a decline over the past 2 years. Her parents have met with the school principal on three occasions during the time period to discuss her failing to near-failing grades in her classes. After meeting with the principal, the parents, mainly the mother, would talk with the Shyla about improving her grades. Sometimes it would result in a “shouting match.” Usually, within a month, Shyla’s grades would show a steady improvement. This would last for 3–4 months and then decline again. Since there is an array of possible diagnoses related to the patient’s behavior, the behavioral health consultant suggests conducting a structured interview with the patient. The Diagnostic Interview Schedule for Children (DISC) was brought up as a possibility. The resident was not very familiar with this instrument. Therefore, he decides to investigate its application for this particular case.


There are advantages of employing the DISC scoring algorithms for mental health diagnoses. It has been reviewed and approved by the National Institute of

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Mental Health (NIMH). Also, since the DISC is a highly structured interview, the administration of the computerized version requires no clinical and little hands-on training. In terms of the instrument’s reliability and validity, the DISC has been widely used since 1983. Since that time, there have been many inquiries and reviews as to its reliability (e.g., tests and retests). Although there may be some detractors, the DISC appears to have a history of reliable and valid results. Reliability is concerned with the consistency of a measurement or instrument over multiple applications. With a survey or questionnaire, it is the consistency of the results over time with the same individual or the consistency within a set of items administered at the same time. While reliability is focused on the consistency of the instrument, validity is concerned with its accuracy. Does the instrument measure what it is expected to measure? A test could be reliable or consistent over time. However, it might not be an accurate or valid measure. This term can be further categorized into internal and external validities. A common metaphor used to describe the relation between these two concepts is a dartboard or target. The objective is to hit the center (i.e., the bull’s eye) of the board. One possibility may involve a tight grouping of darts on the periphery of the board. The results would be considered very reliable but not valid or accurate (i.e., totally missing the center). The ideal case is for all the darts to hit the bull’s eye. This result would be both reliable and valid. There are many types of reliability. For this chapter, two types are discussed: internal reliability (or internal consistency) and inter-rater reliability. Internal reliability assesses the consistency (correlation) among the responses from the items (e.g., questions) within the same instrument (e.g., test, survey). Inter-rater reliability assesses the consistency of the raters’ or observers’ assessment of the same event. One popular measure of internal reliability is Cronbach’s alpha. It is a reliability coefficient, ranging from 0 to 1 (values close to 1 are considered to reflect a high reliability). Values of 0.7–0.8 are regarded as satisfactory; however, clinical applications require higher values (Bland & Altman, 1997).1 A way to gauge for inter-rater reliability is Cohen’s kappa. Its values range from 0 to 1. Values less than 0.4 are considered to be “poor,” 0.4–0.6 are “moderate,” 0.6–0.8 are “substantial,” and above 0.8 are “almost perfect.”2 Internal validity is the extent to which the observed results demonstrate a causal relationship between the variables (dependent and independent) examined. In other words, to what extent do the studied independent or explanatory variables cause a variation (one way or another) in the dependent or outcome variable? It is the degree to which valid conclusions can be drawn about the causal effects of one variable on another (Vogt, 2005). External validity is the ability to apply the test results outside the study or generalize them to another or larger group.

1 2

For the calculations of Cronbach’s alpha, see Campbell and Machin (1999, pp. 174–175). For the calculations of Cohen’s kappa, see Campbell and Machin (1999, p. 175).


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Case Vignette 15.2.3 Conclusion Before committing to the DISC as a diagnostic tool, the resident further examines its reliability and validity. For internal consistency, the calculated Cronbach’s alpha was 0.89. This is more than satisfactory. For inter-rater reliability, the calculated Cohen’s kappa was 0.72, considered substantial. Finally, for external validity, the resident gains permission to review past medical charts from different clinics where the DISC was used. He then compares DISC results with physicians’ diagnoses. For the most part, the outcomes were consistent. The resident continued to evaluate its validity by comparing a small group of at-risk patients (potential for suicidal thoughts or actions based on DISC results) with their follow-up appointments. His investigation validates the DISC results as many of these patients later admit to have had suicidal thoughts and some have attempted to act on it. In the end, the resident decides to administer the structured interview with the patient. After running the computerized version and reviewing the results with the DSM-IV, the resident felt better equipped to diagnose the patient. Shyla was diagnosed with depression and anxiety disorder. Six months later with the behavioral treatment and medication, she showed significant and consistent improvement in her behavior.

Case Vignette 15.3.1 Nate As an assignment for his next journal club, Nate, a second-year medical student, was asked to present on the essential elements in critically understanding a journal article. He selected an article from a reputable, peer-reviewed journal on a metaanalysis done on an existing oral hypoglycemic medication (Drug X) that has been on the market for 10 years.3 In his presentation, Nate notes that the authors of the study applied a metaanalysis to examine retrospective data from 40 of 104 relevant studies in which Drug X was used. They proposed that Drug X is potentially harmful because it increases the incidence of cardiac events (i.e., myocardial infarction). Literature searches were conducted using various public and private databases. Inclusion criteria for the meta-analysis included studies that had a randomized control group not receiving Drug X, studies that were conducted for least a period of 20 weeks, and studies with outcome data for cardiovascular events. The average age of the participants was approximately 53 years. Of 13,100 patients on Drug X, 95 experienced a cardiovascular event. Of 12,700 patients not on Drug X, 70 experienced a cardiovascular event. When comparing the treatment group to the control group, the odds ratio for a cardiovascular event was 1.32 (at

3

This fictitious case is loosely based on facts and findings from an article published in the New England Journal of Medicine (Nissen & Wolski, 2007).

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the 95 % confidence interval [CI], 1.04–1.85; p=0.04). The authors concluded that Drug X is associated with a significant increase in the risk of a cardiovascular event.


It is important that consumers of research literature be critical of the method, analysis, and results of any study. Most journal articles offer current and relevant information on research topics of interest. It is the responsibility of health care professionals to be informed and properly evaluate and interpret published studies in order to provide the best clinical care for their patients.

Case Vignette 15.3.2 Continuation After reading the article a few times, Nate made a list of questions to critically examine the methods and results of the published study. The list includes:

(1) Have you critically examined the methods to determine the validity of the study? How was the sample selected (e.g., simple random sample, stratified sampling)? (2) Pretend that you were conducting the study yourself (see the previous case for the checklist of designing a study). Would you do it differently? If yes, how would you change it? Would your changes significantly impact the results of the published study? (3) What do the results mean? (4) Can the findings be applied in a practical sense (e.g., in my practice)? If yes, how can I apply them?

Additional questions for meta-analysis include:

(5) When dealing with multiple studies, you have to deal with multiple study designs, sampling, data collection techniques, and protocols. Were the values from different studies placed on a standard or common scale? (6) How were the data combined into one data set? Do you have access to the original data sets? Did any of the studies in the meta-analysis use the same data set (partial or complete)? This would entail double-counting. (7) Were the studies with opposing or negative results reported?


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Learning Issues A meta-analysis is conducted by gathering data from multiple journal articles to increase its sample size. The data, from various secondary sources, are compiled and considered as one large data set in the analysis. Each study included in the meta-analysis is considered a unit of measurement.

Criteria for an Acceptable Meta-analysis 1. The study objectives were clearly identified. 2. Inclusion criteria of articles in general and specific data to be accepted were established before selection. 3. An active effort was made to find and include all relevant articles. 4. An assessment of publication bias was made. 5. Specific data used were identified. 6. Assessment of article comparability (e.g., controls, circumstances) was made. 7. The meta-analysis was reported in enough detail to allow replication. Source: Riffenburgh (2006, p. 163). Relative risk is a risk ratio comparing the probability of developing a disease in two groups: the incidence of those exposed to a specific risk factor (e.g., smoking and alcohol consumption) and the incidence of those not exposed to the risk factor. It is often applied in prospective data analysis (e.g., cahort studies and clinical trials), where the two groups are selected at the beginning of the study. Consequently, this ratio is not used in case–control studies (retrospective data analysis with a focus on the outcome first). The following example of relative risk examines the influence of alcohol on liver disease (see Table 15.7). The exposure group included men who drank the alcohol equivalent of 50 or more beers a week. The group not exposed to significant alcohol consumption drank the alcohol equivalent of 1–8 beers a week (social drinking). Based on the calculated relative risk, a man who drank heavily was approximately 1.5 times more likely to develop a liver disease than a man who drank socially. The odds ratio is the ratio of two probabilities: the probability that an event will occur (a/c for simplicity, the data in Table 15.7 are used) and the probability that an event will not occur (b/d). It is often used in the analysis of retrospective cases (e.g., case-control studies of rare diseases).

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Table 15.7 Example of relative risk Liver disease Exposure to alcohol

Present

Absent

Totals

Yes (50 or more)

(a) 70

(b) 150

(a + b) 220

No (1–8)

(c) 250

(d) 950

(c + d) 1200

The relative risk is calculated by the following formula: a/(a + b) 70/(70 + 150) 0.318 → → → 1.53 c/(c + d) 250/(250 + 950) 0.208

The odds ratio is calculated by the following formula: 70/250 0.280 a/c → → → 1.77 b/d 150/950 0.158 While the odds ratio is often used as an estimate for relative risk, we can see by applying the same example from Table 15.7 that, the odds ratio is different from the relative risk. A man who drank heavily was approximately 1.8 times more likely to develop a liver disease than a man who drank socially. As the ratios move away from 1, the difference become more apparent.

Case Vignette 15.3.3 Conclusion Nate applies the critical questions to examine the validity of the authors’ claims. Based on the data, methods, and analysis, it is difficult to say with confidence that the association between Drug X and cardiac events is truly noteworthy. Specific reasons include: (1) Methods: The retrospective data come from other multiple sources. Moreover, the authors did not have access to the original source data. This is a considerable limitation. (2) Methods: It appears that most of these studies were not designed to study cardiac outcomes. (3) Analysis: The actual number of cases with cardiac outcomes was relatively small given the sample size. For participants on Drug X, 95 of 13,100 patients experienced a cardiovascular event. For participants not on Drug X, 70 of 12,700 patients experienced a cardiovascular event. (4) Analysis: Although statistically significant (p = 0.04), the odds ratio of 1.32 appears to be low. Nonetheless, to test whether this ratio is relatively high or low, a comparative analysis with other similar drug(s) should be conducted. Ideally, a randomized clinical trial (prospective analysis) should be conducted to properly examine whether a significant causal relationship exist. In the end, it is up


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to an informed practitioner to decide how to interpret and apply the findings of this article and other journal articles in his/her practice.

Review Questions 1. Study designs: A group of clinician-researchers hypothesized that household crowding may be an important risk factor for pediatric obsessive–compulsive disorder (via increased risk for streptococcal pharyngitis). The researchers chose to analyze a database that was derived from one-time surveys of youth attending community high schools that agreed to participate in the study. The surveys included questions on the number of people in the household and structured interview questions to assess for symptoms of obsessive–compulsive disorder. While all students at the high schools were approached for potential participation in the surveys, the only students included in the study were those for whom there was both youth and parental consent. Which of the following statements pertaining to the study design is FALSE: (a) The study would involve retrospective data analysis. (b) This is a cohort study design. (c) This is a cross-sectional study design. (d) Self-selection sampling was done. (e) None of the above. 2. Sensitivity, specificity, predictive values: Based on the following data on Blood Test A used to diagnosis Lyme disease, calculate (a) the sensitivity and specificity of the screening test and (b) the positive and negative predictive values. Lyme Disease Present

Absent

Blood Test A 240 Positive

12,300

Blood Test A 60 Negative

107,400

3. Correlations: If both samples in Case 1 and Case 2 are representative, which case would you rather have?

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M.A. Samtani et al. r2 0.81 0.01

r high(0.90) low (0.10)

N 6 4000

Significance No Yes

Answers 1. Study designs: Answer: (b). 2. Sensitivity, Specificity, Predicative Values: Disease Present

Absent

Test Positive (TP) 240

(FP) 12,300

(TP + FP) 12,540

Test Negative (FN) 60

(TN) 107,400

(FN + TN) 107,460

(TP + FN) 300

(FP + TN) 119,700

(TP + FP + FN + TN) 120,000

TP = True Positives FN = False Negatives

FP = False Positives TN = True Negatives

Sensitivity TP / TP + FN 240/300 = 80 %

Specificity TN / FP + TN 107,400/119,700 = 90 %

Positive Predictive Value Negative Predictive Value TN / FN + TN TP / TP + FP 240/12,540 = 2 % 107,400/107,460 = 99.94 %

3. Correlations: Depending on the purpose of the study, Case 1 or Case 2 could be valid answers. For Case 1, the Pearson r or correlation coefficient is very high (0.9). However, the sample size is very small (N = 6). Also, the results show that it is not statistically significant. Nonetheless, if one is conducting a pilot study and wants to illustrate a very strong effect, Case 1 is the better option. For Case 2, the correlation coefficient (0.10) appears to be very low. However, the sample size is large, and the correlation is statistically significant. For large sample


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sizes, the r can be low and still reach statistical significance. Accordingly, if one wants to illustrate a statistically significant relationship regardless of a very small effect, then Case 2 is the better option.

Appendix: Populated problem-based tables for the case vignettes Case Vignette 15.1

What are the facts? There appears to be a link between long-term use of antipsychotic drugs and movement disorders commonly found in Parkinsonism



There is a relationship between long-term use of this particular atypical antipsychotic drug and movement disorders commonly found in Parkinsonism A significant portion of the variation in occurrence of this movement disorder can be explained by the long-term use of this drug

Have observational or experimental studies been conducted on this topic?

What specific information would you like to learn about? How to select and conduct a study? Study designs Scales of measurement for data collection Types of sampling techniques Sensitivity and specificity tests How to analyze data (e.g., basic statistical tests used to analyze data)

Case Vignette 15.2

What are the facts? 12-year-old girl Mother worried about mental development Difficulty interacting with peers Shy

What are your hypotheses? Possible anxiety disorder Normal separation anxiety or temperamental variation Depression Child abuse

What do you want to know next? Physical appearance (e.g., any bruises, residual marks, etc.) Cognitive awareness of environment Home environment

What specific information would you like to learn about? What are the normal developmental milestones at this age? Other ways to approach and communicate with this girl Available diagnostic tools/instruments Reliability Validity

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Case Vignette 15.2 (Continued)

What are the facts?


Refuses to separate from mother

Posttraumatic stress disorder Nutritional deficiency Possible endocrine disorder (hypothyroidism) Mother is overly concerned



School performance Parents’ disposition (temperament) Possible substance use Possible parental substance use

Case Vignette 15.3

What are the facts? The journal article purports that through the use of meta-analysis, Drug X is associated with a significant increase in the risk of a cardiovascular event

What are your hypotheses? That the study has many limitations and should be treated with cautious reception

What do you want to know next? Of the 64 relevant studies not selected, how many claimed no significant relationship between Drug X and cardiac events

What specific information would you like to learn about? Meta-analysis Relative risk Odds ratio

Bibliography Appleton, D. R. (1990). What statistics should we teach medical undergraduates and graduates? Statistics in Medicine, 9, 1013–1021. Bakeman, R., & Robinson, B. F. (2005). Understanding statistics in the behavioral sciences. Mahwah, NJ: Lawrence Erlbaum. Bell, F. D. (1995). Basic biostatistics: Concepts for the health sciences: The almost no math stats book. Dubuque, IA: Wm. C. Brown. Bland, J. M., & Altman, D. G. (1997) Cronbach’s alpha. British Medical Journal, 314, 572. Bowers, D. (1996). Statistics from scratch: An introduction for health care professionals. West Sussex: Wiley.


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Campbell, M. J., & Machin, D. (1999). Medical statistics: A commonsense approach (3rd ed.). West Sussex: Wiley. Carvounis, C. P. (2000). Handbook of biostatistics: A review and text. New York: Parthenon. Dawson-Saunders, B., & Trapp, R. G. (1990). Basic and clinical biostatistics. Norwalk, CT: Appleton & Lange. Diagnostic Interview Schedule for Children brochure. http://www.promotementalhealth.org/ downloads/DISC %20Brochure.pdf. Accessed 10/18/07. Garb, J. L. (1996). Understanding medical research: A practitioner’s guide. Boston: Little, Brown. Gervin, M., & Barnes, T. R. E. (2000). Assessment of drug-related movement disorders in schizophrenia. Advances in Psychiatric Treatment, 6, 332–343. Greenhalgh, T. (1997). Statistics for the non-statistician. l. Different types of data need different statistical tests. British Medical Journal, 315, 364–366. Greenhalgh, T. (1997). How to read a paper: Statistics for the non-statistician. II: “Significant” relations and their pitfalls. British Medical Journal, 315, 422–425. Harris, M. B. (1995). Basic statistics for behavioral science research. Needham Heights, MA: Allyn & Bacon. Huck, S. W. (2000). Reading statistics and research. New York: Longman. Kerlinger, F. N., & Lee, H. B. (2000). Foundations of behavioral research. Orlando, FL: Harcourt College Publishers. Kuzma, J. W. (1992). Basic statistics for the health sciences. Mountain View, CA: Mayfield. Lang, T. A., & Secic, M. (1997). How to report statistics in medicine: Annotated guidelines for authors, editors, and reviewers. Philadelphia, PA: American College of Physicians. Matthews, D. E., & Farewell, V. T. (1996). Using and understanding medical statistics. Basel: Karger. National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses. National Institute of Mental Health Diagnostic Interview Schedule for Children (NIMH-DISC). http://chipts.ucla.edu/assessment/pdf/assessments/disc for the web.pdf.Accessed 10/18/07 Nissen, S. E., & Wolski, K. (2007). Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. New England Journal of Medicine, 356, 2457–2471. http://content.nejm.org/cgi/content/full/NEJMoa072761. Accessed 10/13/07. Pedhazur, E. J. (1997). Multiple regression in behavioral research: Explanation and prediction. Orlando, FL: Harcourt Brace College Publishers. Petrie, A., & Sabin, C. (2005). Medical statistics at a glance. Oxford: Blackwell. Riffenburgh, R. H. (2006). Statistics in medicine. Burlington, MA: Elsevier. Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-Stone, M. E. (2000). Journal of the American Academy of Child and Adolescent Psychiatry, 39(1), 28–38. Vogt, W. P. (2005). Dictionary of statistics & methodology: A nontechnical guide for the social sciences. Thousand Oaks, CA: Sage.

Chapter 16

Death, Dying, and End-of-Life Care Lori Murayama-Sung and Iqbal Ahmed

All physicians face end-of-life issues during their training and many continue to work in specialties where life and death are part of their daily duties. This chapter addresses a key challenge for physicians who work with older and critically ill patients. At the end of this chapter, the reader will be able to 1. Understand psychological issues surrounding end of life, including stages of grief, psychiatric illness, and psychosocial/spiritual needs 2. Understand what the standard of care is with regards to euthanasia and physicianassisted suicide 3. Discuss sensitive issues with patients including diagnosing death, organ donation, and how to address families at the time of death 4. Understand what palliative care is and when to refer someone to hospice

Case Vignette 16.1.1 Presenting Situation: Kim Mr. Kim is a 63-year-old Chinese man who is admitted for pleuritic chest pain and dyspnea. He has no known medical or psychiatric history except for an 80 pack-year smoking history. He had not sought medical treatment in years but finally decided to seek treatment at the urging of his second wife. After you perform a full work-up, you gently break the bad news to him that he has end-stage lung cancer. You explain to him that his prognosis is poor and that the recommended treatment at this time would be palliative chemotherapy. Mr. Kim barely says a word during this discussion, but you brush this off because he seems “all right” at the time. Later, however, you become concerned that he may be suffering from depression because the nursing staff has witnessed him crying frequently in his room. He also has been barely touching his food.

L. Murayama-Sung Chief Resident, General Psychiatry Program University of Hawai’i John A. Burns School of Medicine


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You decide to address these issues; however, before you do, you try to recall the recent grand rounds on “stages of grief.” You also think about how you will need to differentiate between depression that needs treatment and an adjustment reaction that will dissipate with time.

Please proceed with the problem-based approach! Kubler-Ross’s stages of grief provide a model for the different emotional and cognitive stages that people experience when they are faced with loss. Not everyone progresses through these stages in this particular order and some people skip stages. Table 16.1 describes the stages and offers examples for each of them. In addition to recognizing stages of grief, you need to determine if Mr. Kim meets the criteria for a normal grief reaction (preparatory grief) versus a major depressive episode (Table 16.2). While people can have symptoms similar to those seen in depression, during acute grief the intensity and duration of symptoms appear less. Grief also does not typically have symptoms of extreme guilt or suicidal thoughts. See Chapter 8, Physician–patient relationship for information on breaking bad news.

Case Vignette 16.1.2 Continuation Mr. Kim tells you that for months, he knew that something was “not right” with his body but delayed seeking treatment because of concerns that it could be something bad. He explains that when you initially told him he had end-stage cancer, he felt numb and was in disbelief. However, after a few days, his situation has started to sink in. Mr. Kim admits to feeling sad and anxious with regards to his cancer. He denies actual thoughts of wanting to hurt himself at this time. He also denies any feelings of hopelessness or worthlessness. He does admit to recent weight loss, decreased energy, and some difficulty sleeping due to lower back pain secondary to compression fractures from bony metastasis.

Please proceed with the problem-based approach! At this point, it seems most likely that Mr. Kim may be suffering from a grief reaction. However, in addition to assessing for grief and depression, it is also important to assess for other psychiatric conditions such as anxiety disorders, mood and anxiety disorders secondary to a general medical condition, and delirium.

16 Death, Dying, and End-of-Life Care

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Table 16.1 Stages of grief (Kubler-Ross, 1969) Stage

Example

Denial Anger

Mr. Kim is in disbelief that he has lung cancer Mr. Kim gets angry at himself or his physicians for not recognizing his illness earlier. He also gets angry with God because he feels his situation is unjust Mr. Kim tries to make deals with God or with himself such as “If my cancer remits, I promise I won’t smoke anymore” Mr. Kim starts to feel sad or despondent Mr. Kim realizes that he has cancer, starts to cope with the realities of having cancer, and starts to focus on the treatment and his day-to-day relationships

Bargaining Depression Acceptance

Table 16.2 Determining the differences between grief and depression (Block, 2000; Periyakoil and Hallenbeck, 2002) Bereavement/grief

Depression

Occurs in most terminally ill patients Grief/sadness relapses and remits and is triggered by loss/illness The patient may still find pleasure in things Somatic symptoms are present, including minor changes in sleep, appetite, concentration, and energy level The patient may experience minor guilt. The patient maintains a sense of hope, but what is hoped for may shift with time The patient may have thoughts of a quick, pain-free, dignified death, but this is different from an active desire for death Able to look forward to things in the future The patient may have illusions about the deceased person The patient tries to go back to a normal routine Grooming and hygiene are good Severe symptoms dissipate in < 2 months

Occurs in 1–53 % of terminally ill patients The patient feels overwhelmed in all aspects of life. Depression is constant The patient does not enjoy anything Somatic symptoms can be more severe, including severe sleep disturbances, significant weight loss Severe guilt, worthlessness, hopelessness, and helplessness

Treatment includes increased support with loved ones, support groups, regular contact with physicians, counseling Medications, primarily to help with short-term issues such as sleep

Severe and persistent suicidal ideations

No positive outlook for future Overt psychotic symptoms: hallucinations and delusions Failure to go back to routine Poor hygiene and grooming Severe symptoms persisting beyond 2 months If left unaddressed, can have a direct impact on medical illness and care Treatment can include antidepressants, stimulants, antipsychotics, and ECT

Case Vignette 16.1.3 Continuation When discussing his medical issues, Mr. Kim describes his fear about what will happen to his body and his ability to function as he approaches death. He remembers watching his father die from gastric cancer and is worried that he will experience the same amount of pain. He states that if the pain became unbearable, he would want you to put him out of his misery like those people in the television special he saw on Dr. Jack Kevorkian. Mr. Kim tells you how important it is for him

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to have a dignified death. You pause to think about what other goals patients may have at the end of life.

Please proceed with the problem-based approach! Although Mr. Kim brings up end-of-life issues on his own, for many patients, these discussions are often avoided for various reasons including the following (Larson and Tobin, 2000):

r r r

Patient barriers: The patient may be scared, confused, unaware of the seriousness, or too embarrassed to approach the topic. Cultural or family factors may impede discussions as well. Physician barriers: The physician may feel too nervous to deliver bad news or may not feel adequately trained in delivering this type of news. Systems barriers: With multiple physicians treating the patient, it may be unclear who is responsible for bringing up this discussion.

In order to improve these end-of-life discussions, Balaban [2000] created a fourstep approach described below:

r

r

r r

Initiate end-of-life discussion: – Provide a supportive/sympathetic environment for the patient and his/her family by listening and encouraging open discussions. – Designate a surrogate decision maker. – Elicit the patient’s general ideas about end-of-life care. Clarify prognosis: – – – –

Be frank yet compassionate about their prognosis. It may be necessary to repeat explanations. Clarify the patient’s understanding. Avoid medical jargon.

Identify goals at the end of life: – See Table 16.3. – Discuss goals in terms of medical care. Create a treatment plan: – Help patients understand their medical options including where they will receive their care and about pain management. – Provide recommendations in terms of treatment. – Identify the patient’s preferences with regard to resuscitation. – Discuss palliative care if appropriate.


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Table 16.3 Common treatment goals at the end of life (Block, 2000; Larson and Tobin, 2000) Goals

Ways to approach these topics

1. Maintain sense of identity and operate as independently as possible within the limits of illness and prognosis.

“What barriers prevent you from feeling comfortable and in control as you deal with your illness?” “How would you like your loved ones to remember you?” End-of-life discussions including treatment options can provide sense of control

2. To avoid/limit pain and suffering

“Is pain or the possibility of pain/suffering a concern for you?” Do not say: “There is not much that can be done for you” Instead say: “I believe there is much that can be done to manage your pain, provide you comfort, and assist you in living every day to its fullest”

3. Maintain/enhance important relationships and resolve conflicts with others

“Are there people in your life you want to get closer to or make up with?” “How do you want to tell your loved ones good bye?” Encourage families to share emotions and memories, and collect memorabilia

4. Pursue remaining dreams and setting goals

“When you think about your future, what is of greatest importance to you?” “Are there unresolved issues that you need to take care of and bring closure to?” Help patients come up with goals such as attending their son’s wedding or going to a grandchild’s graduation

5. Finding meaning in life and death

Patients often question what type of legacy they have left behind. Allowing patients to share memories, words of wisdom

6. Preparation for death: being able to hand over control to family and loved ones

“In what ways can you help your family prepare for and cope with your death?” Organize end-of-life plans (living wills, funeral arrangements) Having a frank conversation with the patients about their prognosis and what happens as they are about to die can be helpful Telling the patients that you will be there until the end can be reassuring to patients

During this case, Mr. Kim brought up his goal of having a “good death.” End-oflife conversations should include finding out from patients what their goals are even if faced with a terminal illness. Some common goals that people have at the end of life and ways to phrase these conversations are provided in Table 16.3.

Pain Management in Palliative Care Another issue that Mr. Kim was trying to ask is “Will my pain be addressed?” This is an important concern for many end-of-life patients that is often incompletely addressed as evident by the SUPPORT study (The SUPPORT Principal Investigators, 1995).

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When evaluating pain for palliative care patients, the physician must assess etiology, quality, severity, timing, and relieving/exacerbating factors. Principles for pain management (particularly with cancer patients) include the following (World Health Organization, 1986; Jacox et al., 1994):

r r

r r r r r

Mild to moderate pain: nonopioid analgesics (NSAIDs, aspirin, acetaminophen) +/− adjunctive agents. Moderate to severe pain: addition of opioid analgesics, to provide additive analgesic effects. – Moderate pain: opioids like codeine or hydrocodone. – Moderate to severe pain: use higher potency opioids like morphine, methadone (long half-life), or fentanyl (short half-life). When prescribing for patients with chronic pain, it is better to have scheduled rather than PRN analgesics to decrease break-through pain. Other adjunctive agents can be used for various types of pain. Medications such as tricyclic antidepressants or gabapentin can be used in neuropathic pain. Behavioral techniques such as relaxation techniques, biofeedback, or cognitive restructuring can be used as well. Physical methods, such as heat/cold and acupuncture, may be tried. Treat co-morbid psychiatric conditions, which can increase the patient’s subjective experience of pain.

Physician-Assisted Suicide and Euthanasia Euthanasia is when the physician actively participates with intentionally ending a patient’s life. It is illegal and considered a criminal act in all states but some countries like the Netherlands have regulated systems for it (Van der Heide, 2007). Physician-assisted suicide (PAS) is when the physician provides the patient with medications, interventions, or information that the patient will use to commit suicide. While this is currently legal in Oregon, many medical organizations such as the American Medical Association have made statements against these practices (American Medical Association, 2005; Emanuel, 2002). Many Americans support euthanasia and PAS for those in severe pain (Emanuel, 2002). Pain, however, does not appear to be the main reason why people request these interventions. Psychosocial and existential factors appear to play more of a role. According to a systematic review performed by Hudson et al. [2006], depression/hopelessness, burdening others, loss of autonomy, physical symptoms, anxiety about the future, and existential worries were common themes behind these requests. If Mr. Kim were to bring up the topic of PAS/euthanasia, it would be important to consider the following:

r r

How serious is the request? → Was Mr. Kim just reacting to his current situation or was he actually seeking information or assistance? What is the underlying reason for wanting PAS/euthanasia? → Mr. Kim discussed his concerns about unaddressed pain.


r r r r

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Do not assume that a decision is final. Studies have shown that depression and hopelessness have strongly been associated with requests for euthanasia or PAS and that such requests can dissipate with time (Chochinov et al., 1995; Emanuel, 2002). Assess for psychiatric symptoms and even consider a psychiatric consultation → is depression contributing to Mr. Kim’s request? Find out about the patient’s support system. Educate the patient that alternatives such as treatment withdrawal, aggressive management of pain (even if it may shorten the patient’s life), and withholding fluids or nutrition are legal and is not considered PAS.

Case Vignette 16.1.4 Continuation Over the next 2 weeks, Mr. Kim appears to have accepted his prognosis. You initiate a discussion about his end-of-life goals. He reflects on all the things he would still like to accomplish, especially since he has only been married to his wife for 2 years. He describes the plans they had to travel to Europe when he retired at 65. He also tells you that he has not spoken to his three adult children for several years after a bitter divorce from their mother and how he would like to reconcile with them. He worries about his wife, who also has multiple medical problems, and asks you if his death could possibly impact her health. You ask Mr. Kim whether faith or religion is an important part of his life. He says that he has not attended church in years but would like to speak with the hospital chaplain.


Impact of Death on the Surviving Spouse Studies have shown that the loss of a spouse can significantly impact the physical and psychological health of the survivor. Rates of hospitalizations and mortality increase (Greenblatt, 1978) with higher rates from accidental, alcohol-related causes, and violent means and moderate increases from lung cancer and ischemic heart disease (Martikainen and Valkonen, 1996).

Spirituality and Religion at the End of Life Physicians are often uncomfortable asking about faith, but as Mr. Kim has shown, spirituality can play an important role for the terminally ill. Research has shown that only 10 % of physicians discuss spirituality with their patients despite 65–95 %

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of patients wanting this addressed (Puchalski, 2002). Thus, simply asking “Is your faith important to you in this illness?” can open up the discussion (Larson and Tobin, 2000). Religion or spirituality can be the way that people explore the meaning of their death and cope with their dying process. Studies have shown that spiritual wellbeing can help with cognitive symptoms of depression in elderly medical inpatients (Koenig et al., 1995). It can also be a protective factor against despair experienced at the end of life (Puchalski, 2002). Discussions about faith are important because many religions have certain beliefs about end-of-life care. Finding out the patient’s religious background and specific needs during the dying process can show commitment to caring for the patient as a whole. For example, some religions want their religious leaders present at the time of death (Roman Catholics have last rites) or have special requests for the care of the body before and after the patient’s death. Certain religions, such as Islam and Judaism, also have traditions that can impact autopsy or organ donation (Kahn et al., 2003)

Case Vignette 16.1.5 Continuation Mr. Kim then asks you about hospice and about the process of organ donation because the social worker came in earlier asking if he would like more information. As you glance over his chart, you notice that his code status has not been addressed, therefore you ask him about his resuscitation wishes.

Hospice/Palliative Care Mr. Kim asks you about hospice, but before this topic can be discussed further, the general principle of palliative care should be discussed. The goals of palliative care are to enhance quality of life and relieve pain and suffering for patients with advanced disease (Morrison and Meier, 2004). It is a multidisciplinary approach that addresses psychosocial as well as spiritual issues and offers support to patients and families. Palliative care may be offered alongside other medical treatments. It aims to neither quicken nor delay death. In order to qualify for hospice, a patient must be deemed to be terminally ill with a life expectancy of 6 months or less (Morrison and Meier, 2004). The patient and their family’s goals must be directed at symptom relief rather than curative treatments aimed at prolonging life.

Organ Donation In this vignette, Mr. Kim asks about the process of organ donation and the criteria for it. Most sources for organs are brain-dead donors with intact circulation (Hauptman and O’Connon, 1987).


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Previously, the criteria for organ donation were strict with potential donors being under 50 with limited co-morbid conditions. Today, there is no national standard in terms of absolute or relative contraindications. Transplant centers each have their own criteria, often on a case-by-case basis because of the few absolute contraindications. Patients and their families may need to understand the concept of brain death and the process of organ donation in order to decide what is best for them.

Case Vignette 16.1.6 Continuation After discussing his code status with you, Mr. Kim decides that he does not want life-sustaining measures if there is no hope for recovery or if he is unable to interact with his family. He names his wife as his Durable Power of Attorney (DPOA) in case he becomes incapacitated and is unable to make medical decisions for himself. Several days later, Mr. Kim’s respiratory function rapidly deteriorates. He becomes increasingly hypoxic and less responsive. Sensing the gravity of his situation, you gather his family members, including his estranged children. Because of his previously stated wishes, you prepare to deliver comfort care to minimize his feelings of dyspnea as well as his bony pain. There is conflict, however, among the newly arrived family members. They are pushing for intubation despite the patient’s wishes. You are frustrated by Mr. Kim’s children who demand aggressive treatment against his stated wishes.

End-of-Life Discussions with Family Members The conflict between Mr. Kim’s and his family’s wishes is a common theme seen in the hospital. Here are some ways to address this issue (Balaban, 2000; Weissman, 2004):

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Understand that acceptance of the patient’s prognosis occurs differently for different people. Often times it is more difficult for families to accept the patient’s impending death than it is for the patient. Go over clinical information with the patient and his/her family in a manner that is simple and jargon-free. Allow the patient and his/her family time to express their feelings and ask questions. Sometimes families want “everything done” despite the patient having a poor prognosis. In these cases, it is important to uncover the underlying motivation. Assessing the family dynamics can provide insight into unresolved issues or conflicts. Occasionally, families may not realize the futility of treatment; therefore, prognosis should be discussed. If these discussions are unable to progress, the ethics committee or legal counsel can help.

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Case Vignette 16.1.7 Continuation You arrange a family meeting to ascertain the family’s understanding of Mr. Kim’s condition and overall prognosis. His children repeatedly ask, “Why can’t we use machines to help him breathe so we can keep him alive until he recovers?” They also ask why he is unresponsive and whether he is brain dead. You explain to them the difference between coma and brain death.

Diagnosing Death Mr. Kim’s family brings up a topic that can often be confusing for families. Table 16.4 helps to distinguish between persistent vegetative state (PVS), coma, and brain death. While there are differences in opinion with what to do with patients in a PVS, if a patient is diagnosed as being brain dead, they are considered legally dead. Once a person is considered legally dead, organ donation can commence and life support can be disconnected.

Case Vignette 16.1.8 Conclusion Soon after the family meeting, there is a call from Mr. Kim’s nurse saying that he is increasingly tachycardic and tachypneic. Family members at the bedside are distressed by his breathing pattern and are asking for measures to make him comfortable. “He looks like he’s drowning. Can’t you do something?” After you give him morphine to make him feel better, he eventually becomes more hypoxic with agonal breathing, progressing to complete unresponsiveness and asystole.

Table 16.4 Differentiating between various states of conscious (Multi-Society Task Force on PVS, 1994) Persistent vegetative state

Coma

Brain death

The patient is awake and has sleep/wake cycles but is unaware of himself/herself and his/her surroundings Hypothalamic and brain-stem autonomic functioning is intact but there are no purposeful responses to stimuli

Sustained unconsciousness Can progress to consciousness, PVS, or death

Irreversibly comatose Legally dead; therefore, life support is futile

Due to dysfunction in the ascending reticular activating system (which can be damaged at the site of the brain stem or both cerebral hemispheres). The patient is unable to be aroused, and this status lasts longer than 1 h

Absence of all brain functions including the brain stem, reflexes, and cranial nerves


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As you are performing the “death pronouncement,” you can hear the family sobbing at the bedside. You then turn to them and say “I’m very sorry. When you are ready, we can meet in the family room where we can talk and I can answer any questions you may have.”


How to Address the Family at the Time of Death (Jurkovich et al. 2000; Williams et al., 2000) Addressing Mr. Kim’s death with his family is difficult, but here are some ways to improve these conversations with families:

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Meet the family in a private area. Identify their relationships to the deceased. Families like to be told in a sympathetic and unrushed manner what happened. Use the patient’s name rather than “the patient.” Advise them if an autopsy is required. Allow the family to ask questions and express their feelings. Allow them time to view the deceased, and prepare them if there are any medical devices left or if the body has been altered physically. Assist the family with what to do next (e.g., how to make funeral arrangements, when they can go home). Offer to request a visit from a pastoral counselor. Give handouts about the grieving process.

Review Questions 1. Which of the following is more likely a sign of depression rather than attributable to a grief reaction? a. Difficulty sleeping for several days b. Minor guilt c. Feelings of worthlessness 2. What are the stages of grief? 3. What are the three goals people commonly have at the end of life? 4. What is a typical pharmacologic approach to treating cancer patients with moderate to severe pain?

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5. What are the goals of palliative care? 6. True/False: a. Euthanasia is legal in the USA. b. Physician-assisted suicide is illegal in all states. 7. Is a patient in a persistent vegetative state considered brain dead?

References American Medical Association. E-2.211 Physician-assisted suicide. Last updated 2005. http://www.ama-assn.org/ama/pub/category/8459.html. Accessed 11/1/07. Balaban RB. A physician’s guide to talking about end-of-life care. Journal of General Internal Medicine 2000; 3: 195–200. Block SD. Assessing and managing depression in the terminally ill patient. Annals of Internal Medicine 2000; 132: 209–218. Cancer pain relief. Geneva: World Health Organization, 1986. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, and Clinch JJ. Desire for death in the terminally ill. American Journal of Psychiatry 1995; 152: 1185–1191. Emanuel EJ. Euthanasia and physician-assisted suicide. Archives of Internal Medicine 2002; 162: 142–152. Greenblatt M. The grieving spouse. American Journal of Psychiatry 1978; 135: 43–47. Hauptman PJ and O’Connon KJ. Procurement and allocation of solid organs for transplantation. New England Journal of Medicine 1987; 333(6): 422–431. Hudson PL, Kristjanson LJ, Ashby M, Kelly B, Schofield P, Hudson R, Aranda S, O’Connor M, and Street A. Desire for hastened death in patients with advanced disease and the evidence based of clinical guidelines: a systematic review. Palliative Medicine 2006; 20; 693–701. Jacox A, Carr DB, and Payne R. New clinical-practice guidelines for the management of pain in patients with cancer. New England Journal of Medicine 1994; 330: 651–655. Jurkovich GJ, Pierce B, Pananen L, and Rivara FP. Giving bad new: the family perspective. The Journal of Trauma: Injury, Infection, and Critical Care 2000; 48: 865–870. Kahn MJ, Lazarus CJ, and Owens DP. Journal of Clinical Oncology 2003; 21(15): 3000–3002. Koenig HG, Cohen HJ, Blazer DG, Kudler HS, Krishnan KR, and Sibert TE. Religious coping and cognitive symptoms of depression in elderly medical patients. Psychosomatics 1995; 36(4): 369–375. Kubler-Ross E. On death and dying. New York: Macmillan, 1969. Larson DG and Tobin DR. End of life conversations. Journal of the American Medical Association 2000; 284(12): 1573–1578. Martikainen P and Valkonen T. Mortality after the death of a spouse: rates and causes of death in a large Finnish cohort. American Journal of Public Health 1996; 86(8): 1087–1093. Morrison RS and Meier ED. Palliative care. New England Journal of Medicine 2004; 350(25): 2582–2590. Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state—first of two parts. New England Journal of Medicine 1994; 330; 1499–1508. Periyakoil VS and Hallenbeck J. Identifying and managing preparatory grief and depression at the end of life. American Family Physician 2002; 65(5): 883–890, 897–898. Puchalski CM. Spirituality and end-of-life care: a time for listening and caring. Journal of Palliative Medicine 2002; 5(2): 289–294. The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Journal of the American Medical Association 1995; 274(2): 1591–1598.


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Van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, Van Delden JJM, Hanssen-de Wolf JE, Jansses AGJM, Pasman HRW, Rietjens JAC, Prins CJM, Deerenberg IM, Geveres JKM, Van der Maas PJ, and Van der Wal G. End-of-life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine 2007; 356: 1957–1965. Weissman DE. Decision making at a time of crisis near the end of life. Journal of the American Medical Association 2004; 292(14): 1738–1743. Williams G, O’Brien DL, Laughton KJ, and Jelin GA. Improving services to bereaved relatives in the emergency department: making healthcare more human. Medical Journal of Australia 2000; 173: 480–483.

Part IV

Behavioral Neuroscience and Clinical Psychiatry

Chapter 17

Basic Principles of Evaluation: Interviewing, Mental Status Examination, Differential Diagnosis, and Treatment Planning Anthony P.S. Guerrero, Daniel A. Alicata, and Nathanael W. Cardon

This chapter helps bring everything you are learning full circle as we discuss the actual patient encounter. We compare and contrast the psychiatric evaluation to that of general medicine and describe what is expected in your psychiatric clerkship as you examine, diagnose, and develop a treatment plan. This chapter provides the context for applying the principles of psychiatry. At the end of this chapter, the reader will be able to 1. Discuss the basic structural components of a psychiatric interview, including history and mental status examination 2. Discuss the basic principles to guide the process of an effective interview, including establishing and maintaining rapport, prioritizing safety, and efficiently gathering data sufficient to yield a differential diagnosis 3. Discuss the process of differential diagnosis according to the DSM-IV-TR 4. Discuss the process of bio-psycho-social-cultural-spiritual formulation and treatment planning

Case Vignette 17.1.1 Dan, Tony, and Melissa Dan, Tony, and Melissa are second-year medical students who are starting their “brain and behavior” clinical skills preceptorship. They are quite apprehensive about performing their first interview, because they believe that “everything is totally different when it comes to ‘psych’.” Students often worry that the basic history and examination skills they learned on other clinical services will not work in psychiatric settings. In reality, the entire assessment and treatment planning process learned in other parts of medicine are completely relevant to psychiatry, with a few relevant adaptations, as shown in Table 17.1.

A.P.S. Guerrero Associate Professor of Psychiatry and Pediatrics, Associate Chair for Education and Training, Department of Psychiatry, University of Hawai’i John A. Burns School of Medicine


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Table 17.1 Components of the psychiatric assessment Traditional “medical exam” component

Psychiatric assessment component

Identifying data Source and reliability Chief complaint History of the present illness, with attention to “pertinent positives” and “pertinent negatives”

Same Same Same Same—with attention to the psychiatric review of systems and the different psychiatric and general medical conditions that should be “ruled in” and “ruled out” Same plus a specific past psychiatric history Same—with attention to psychiatric conditions Same—often more lengthy because of the role of social factors in psychiatric illness Same—because general medical conditions (detectable in the review of systems) can often explain psychiatric symptoms Same—with more emphasis on the neurological exam and the MSE as a detailed branch step of the physical examination Mental status examination (described further below) Psychiatric formulation and differential diagnosis, based on the DSM-IV-TR Same

Past medical history Family history Social history Review of systems

Physical examination

Problem list and assessment of each problem Plan, with additional information/diagnostic testing, specific treatments, and patient education

Case Vignette 17.1.2 Continuation The three students feel less anxious, knowing that they can apply the skills that they have already learned. They successfully meet the requirements of the preceptorship. The three students are now third-year medical students new to the psychiatry clerkship. They each are about to do their first patient interview for the clerkship. Dan, who received positive recognition in his previous clerkships for his patience and his excellent bedside manner, states: “All I need to do is listen, and I think the patient will tell me what I need to know in 30 minutes (which is the time allotted to the interview).” Tony, who was recognized in his previous clerkships for his high exam scores, states: “I think I have everything figured out: all I need to do is ask the patient everything in this master template that I made, and everything will be fine.” Finally, Melissa, who was recognized in her previous clerkships for her overall stellar performance, states: “I’ve never had a problem interviewing patients. I just need to get Honors in this clerkship because I want to go into a competitive specialty.” Following their first interview, the three students are flustered. In a de-briefing meeting with their clinical supervisor, Dan states: “I couldn’t get a word in during

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the interview. All I was able to find out was that this patient is married and that he is a Christian. I was totally lost during the rest of the interview, and I didn’t want to interrupt him because it seemed like he would get mad.” Tony states: “Even though I kept telling the patient how important it was to answer all of my questions, all he could do was give one-word answers, look quickly from one side of the room to the next, and then ask to go back to his room . . . which he did anyway after only 15 minutes. I ran out of time and we didn’t even get to why he overdosed.” Melissa states: “Because my patient kept crying so much, I didn’t get a chance to test all of that important stuff for psychiatry, like ask about rolling stones gathering no moss and what to do with a stamped envelope.” Their supervisor, hoping to help their subsequent interviews with these patients to go smoother, encourages them to think of the interview as an opportunity to apply the problem-based approach. “What do you mean?” they ask. The preceptor encourages them to proceed with a modification of the familiar problem-based approach. Although this is not the typical problem-based learning scenario, use of a modified PBL table may be helpful in guiding the process of the interview, as shown in Table 17.2.


Table 17.2 Modified PBL table for Case Vignette 17.1.2 What are the observations about the process of the interview?

What are the hypotheses about why the interview is going this way?

What might I need to ask about and/or do next?

(for Dan)

Bipolar mania Schizophrenia Methamphetamine intoxication

Summarize, ask clarifying questions Do one’s best to elicit relevant history

Suspicion about the interview process Irritability from depression

Ask about and try to optimize patient’s comfort Re-orient patient to purpose and context of interview Do one’s best to elicit relevant history

Depression Grief

Recognize patient’s emotions and provide empathic comments as appropriate

Difficult to interrupt patient “I’m lost” (for Tony) One-word answers Looking quickly from one side of the room to the next Wants to go back to room (for Melissa) Crying so much

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While the structural elements of the psychiatric interview are essentially identical to elements of the general medical interview, a distinguishing characteristic of psychiatric interviewing is the likelihood that the very illness that one is trying to assess (such as the primary mood or psychotic disorder that Dan’s patient above likely was demonstrating symptoms of) may impact the very process of the interview. Whenever something unexpected happens in an interview (ranging from intense tearfulness, to a request to leave the interview early, to an unusual question being asked of the interviewer), the most appropriate next step is often to use this occurrence as an opportunity to gather more information about what might be happening. For example: “I notice that you’re really wanting to go back to your room . . . We’ll be done in a few minutes, but I wonder if you could tell me what you’re thinking right now or if there’s anything we could do to help you feel more comfortable right now.” Even though it is easy to remember what the structural elements of an interview should be, students often feel challenged in getting through a “complete interview” in a time-limited period—which often needs to be done in real-life situations. We suggest that, during a time-limited interview, students should establish the following priorities: 1. Attempt to establish and maintain rapport through

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Unconditional positive regard for the patient and attentiveness to patient comfort. This can be conveyed through a friendly demeanor and supportive and empathic statements (“That must have been a tough time for you”). Adequate preparation for the interview (explaining the context). Appropriate use of open-ended (yet context-appropriate) questions, such as “What happened that led to your hospitalization?” or “Could you tell me more about that?” or “What’s your understanding of what the medications are being prescribed for?” Responsiveness to the patient’s emotions and other potential barriers to effective rapport. For example, Tony observed irritation in his interview, and Melissa observed overwhelming sadness during her patient interview but neither responded to the patient’s mood state. Failure to address such barriers may interfere with subsequent data-gathering and may be more time-costly in the long run.

2. Assess safety, specifically

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Suicidality and thoughts of violence toward others: current ideations as well as previous dangerousness, command hallucinations, acute stressors, mood symptoms; and (if a recent attempt had been made), degree of premeditation (including suicide notes and other preparatory acts), method of discovery, perception of lethality, and what the patient perceives as having changed since the attempt. (Apparently, Tony did not prioritize this in his interview). Abuse and being victimized (particularly for minors and dependent adults).


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Serious psychotic symptoms that impair reality testing and would interfere with a patient’s ability to meet basic needs. Serious general medical conditions. Substance intoxication and/or withdrawal (which could be life-threatening).

3. Attempt to elicit history and examination findings to at least establish a differential diagnosis (not necessarily the definitive diagnosis—which may be unrealistic to determine in a short period of time):

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Pertinent positives and pertinent negatives, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, currently in its fourth edition, text revision (DSM-IV-TR). To the degree possible, review of the key areas of history and psychiatric review of systems.

Another distinguishing characteristic of the psychiatric interview is the need to thoughtfully perform a mental status examination (MSE). While it may initially seem (as it probably did to Melissa) that the mental status examination is an academic exercise with little relevance to the rest of medicine, each of the elements has practical clinical relevance and represents an indirect assessment of neurological functions. Detailed descriptions of observations are more clinically relevant than clinical jargon. A good MSE will “paint a picture” of the patient at the time of the exam. The components of the MSE are summarized in Table 17.3. Following the psychiatric interview and mental status examination is the biopsycho-social-cultural-spiritual formulation (discussed in Chap. 1) and a differential diagnosis according to the DSM-IV-TR, which describes diagnostic assessment according to the following five axes: Axis I Major psychiatric conditions (all psychiatric conditions other than personality disorders and mental retardation; includes substance use disorders) Axis II Personality disorders and mental retardation Axis III General medical conditions Axis IV Stressors (e.g., primary support group, occupational, educational, legal, other social) Axis V Global assessment of functioning: current and in the past year (on a scale of 0–100; examples: 70 = mild impairment, 60 = moderate impairment, 50 = severe impairment, 40 = impairment of reality testing, 20 and below = acute dangerousness) It may sometimes seem that the checklist approach used by the DSM-IV-TR for diagnosing psychiatric disorders is “cookbook” medicine because there is no “gold standard” along the lines of a definitive blood test or histopathological finding. However, it should be noted that other medical conditions, such as rheumatologic disorders and disorders affecting multiple systems, are diagnosed and very effectively treated through a similar approach.

Observation

Observation

Observation

General appearance

Eye contact

Cooperation with interview Motor activity

Observation

Direct questioning about how the patient has been feeling; rate mood from 1 to 10, 10 = best possible

Speech

Mood—expressed emotional state

Observation; sometimes formal testing for abnormal motor movements, tremor, and/or rigidity

How assessed

Mental status examination component

Table 17.3 Components of the mental status examination

Euthymic, depressed, anxious, expansive, irritable

Normal or increased or decreased rate and/or volume and/or amount; normal (or not) clarity

Cooperative with interview, guarded, etc. Psychomotor agitation or retardation (or none), abnormal motor movements (or none), tremor and/or rigidity present (or not)

Well developed, well nourished, thin, overweight, good/poor hygiene, no obvious deformities, etc. Good, adequate, fair, poor, etc.

Sample descriptive terms

Hypothalamus, limbic system, other parts

Multiple areas, including speech centers

Basal ganglia, motor cortex, other areas

Multiple

Multiple

Multiple

Part(s) of the brain being tested or neurobiologic mechanisms

May be decreased as a result of depression or distraction from hallucinations, etc. Several conditions can impact upon rapport Major depression may cause psychomotor retardation, while mania may case psychomotor agitation. Antipsychotic medications may cause abnormal motor movements, tremor, and/or rigidity Mood disorders and/or substance intoxication may affect the rate, volume, and/or amount of speech. Neurological conditions (that may also cause psychiatric symptoms) may affect clarity of speech Mood disorders and/or substances may affect patient’s reported mood and observed affect

Patients whose illness affects ability to care for self may have significant findings on general appearance

Examples of practical clinical relevance

236 A.P.S. Guerrero et al.

Observation

Observation

Observation, some direct questions

Thought process

Thought content

How assessed

Affect—observed emotional state


Table 17.3 (continued)

Mood-congruency (mood-congruent, mood-incongruent) Range (broad, restricted, flat) Lability (labile or not) Overall quality (neutral, depressed, anxious, euphoric, irritable) Linear (remains on topic) and goal-directed, circumstantial (goes off topic but eventually returns to the original topic), tangential (goes off topic without ever returning to the original topic), flight of ideas (without production of a coherent thought), word salad (in which even the individual words may not coherently link together) Delusions (present or not, with specific examples); paranoid ideations (present or not, with specific examples); future orientation; etc.


Inappropriate mesolimbic dopamine release, poor cortical filtering; other areas


Primary psychotic disorders such as schizophrenia and/or substances may affect result in delusions; depression with suicidal ideations may lead to a patient not having a future orientation

Primary psychotic disorders such as schizophrenia and/or substances may affect thought processes


17 Basic Principles of Evaluation 237

Direct questions, with some observation

Direct questions, with some observation

Direct questions

Orientation

Concentration

Memory

Alertness

Direct questions, with some observation for distractibility of other evidence of response to internal stimuli Observation

How assessed

Perceptions



Reticular activating system Often depends on alertness and memory

See above, relevant sensory cortices (auditory, visual, etc.)

Able (or not) to perform serial 7’s (“take the Reticular activating number 100, subtract 7, and then keep system subtracting 7 from your answer until I tell you to stop . . .”) Able (or not) to spell five-letter words such as “world” or “ocean” backward. (Usually, one of these tests will suffice) Ability to immediately recall three unrelated Hippocampus (memory words that are not objects in the room (e.g., encoding), other parts “umbrella,” “car,” “happiness”) and to of the cerebral cortex recall these words approximately 5 minutes later (if not spontaneously recalled, prompting or giving hints may suggest more impairment of memory retrieval than memory storage) Longer-term memory may be assessed by asking the last five presidents, etc.

Oriented (or not) to person, place, time (date, month, year), situation

Auditory and visual hallucinations (present or not); appearance (or not) of seeming to respond to hallucinations; other hallucinations (e.g., tactile, olfactory, etc.) also important to note if present Alert, drowsy, stuporous, comatose



Dementia results in memory impairment along with other cognitive findings. Cortical dementias are associated with memory storage difficulties, while subcortical dementias are associated with memory retrieval difficulties

Delirium may cause fluctuations in level of alertness Delirium may cause disorientation. Other memory-impairing conditions such as dementia may cause disorientation Delirium primarily affects alertness and concentration

Primary psychotic disorders such as schizophrenia, substances, and/or delirium may result in hallucinations


238 A.P.S. Guerrero et al.

Direct questions

Observation, possibly direct questions

Observation, possibly direct questions Direct questions

Abstraction

Judgment

Insight

Suicidality, homicidality, violence

How assessed



Presence or absence: ideations and/or intentions

Ability (or not) to state similarities (e.g., apple and orange are both fruits, table and a chair are both furniture, newspaper and radio both tell the news, opera and a painting are both forms of art) or accurately interpret proverbs (though proverbs often test more than just abstraction) Ability (or not) to exercise good judgment with regards self-care, behaving appropriately Insight into illness, need for treatment


Multiple areas

Frontal lobe

Frontal lobe

Frontal lobe


Important to explicitly cover, in the interests of safety

As above

As above

Schizophrenia often is associated with frontal lobe maldevelopment


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General medical conditions and substance-induced conditions, while often overlooked, are important to include in the differential diagnosis of many Axis I conditions. The final step of the psychiatric assessment is to develop a treatment plan that adequately considers the formulation and differential diagnosis. Please refer to Chap. 1 for a diagrammatic illustration of how a successful plan addresses the various components of a bio-psycho-social-cultural-spiritual formulation. The following shown in Table 17.4 helps to develop a comprehensive plan. We close, in Appendix, with a sample write-up of a fictitious patient (with gratitude to George Lucas, creator of the Star Wars series, where many of the arbitrarily chosen fictitious names came from).

Table 17.4 Treatment planning template Additional information

Biological

Psychological

Social/cultural

Old records (e.g., to look at previous diagnoses and medication efficacy) Insure a recent physical exam Relevant labs, for example:

Additional interviews Speak with previous therapists, etc. Psychological testing: for example, intelligence testing, personality testing, projective testing (to evaluate for psychotic processes)

Talk to family, others if patient gives consent

Family psychotherapy if appropriate Social services, stable living Structured setting—e.g., to remain safe, substance-free, etc. Other resources Family psychoeducation as appropriate

Chemistry profile Complete blood count Thyroid function tests Tests to rule out infection (e.g., syphilis, HIV) Toxicology screen Neuroimaging Treatment

Continue effective medications, usually abstinence from substances

Individual psychotherapy to build rapport Groups—e.g., anger management, Alcoholics/Narcotics Anonymous

Patient education (often covered above)

Education on benefits and side effects of medications

Psychoeducation on need for compliance, crisis resources, etc.


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Review Questions 1. You are interviewing a patient, who suddenly becomes very quiet and possibly tearful when the topic of her childhood is discussed. The next most appropriate thing to do is to (a) Switch the topic to something less sensitive. (b) Immediately perform a cognitive examination. (c) Recognize the change in affect and empathically acknowledge the likely difficulty in discussing such a topic. (d) Immediately terminate the interview and postpone any further attempts at interview until the patient can regain composure. (e) Reassure the patient that you know exactly how she feels, and that it is perfectly okay to cry. 2. During the course of a diagnostic interview, your patient asks, for a second time, “Doctor, how old are you, anyway?” Which of the following is the best response? (a) “Once again, this interview is about you, not about me, so let’s talk about something else.” (b) “I’m old enough to be a physician and old enough to be interviewing you.” (c) “I’m very uncomfortable talking about my personal life with patients.” (d) “I notice that you’re really interested in how old I am. I wonder what your thoughts are behind wanting to know.” (e) “I’m somewhere between 20 and 60.” 3. All of the following statements are correct EXCEPT (a) Affect describes one’s observation of the patient’s emotions during the interview. (b) Mood describes what the patient’s emotional state has generally been. (c) Mood can be elicited through direct questioning of how the patient has been feeling. (d) Tangential thoughts never return to the original topic or question. (e) Circumstantiality is pathognomonic for a psychotic disorder. 4. Which of the following statements best describes the role of testing “serial 7’s”? (a) Difficulties with this test may indicate delirium. (b) This test is intended to primarily test mathematical abilities. (c) Difficulties with this test always reflect dysfunction of the reticular activating system. (d) Psychotic individuals invariably have difficulty with this test. (e) This test must always be done in combination with asking the patient to spell “world” forward and backward and recall digit spans. 5. Which of the following statements about psychiatric assessment are correct? (a) A bio-psycho-social-cultural-spiritual formulation, because of its inherent inclusion of “psychiatric jargon” terms, is rarely useful for patients or other health professionals involved in patient care.

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(b) Effective rapport is the foundation for all patient interviews, whether in psychiatry or in any other specialty of medicine. (c) Psychiatrists should never perform physical examinations or order laboratory studies. (d) Assessment of safety is merely an assessment of current suicidal or homicidal ideations. (e) Learning disorders and pervasive developmental disorders are noted on Axis II.

Answers 1. c, 2. d, 3. e, 4. a, 5. b

Appendix Sample Write-Up Name: Luke Skywalker, MS3 Attending Psychiatrist: Master Yoda, M.D. Date: 05/01/2008 Identifying Data: Princess Leia is a 34-year-old cosmopolitan female, divorced, employed as a secretary. Reason for Examination: Psychiatric consultation for patient on the general medical ward; medical student write-up #1. Referring Physician: Obi-Wan Kenobi, M.D. (internal medicine). Source and Reliability: Patient, who appears fairly reliable. Chart also reviewed. Chief Complaint: Acetaminophen overdose. Summarize information relevant for eventual formulation and differential diagnosis

History of the Present Illness: Ms. Leia is a 34-year-old female admitted last night for an acetaminophen, acetaminophen/oxycodone, and ibuprofen overdose. This overdose occurred late yesterday afternoon (Saturday) at her apartment. She ingested several extra strength acetaminophen tablets, a few acetaminophen/oxycodone tablets, and a few ibuprofen tablets following an argument with her boyfriend over his recent infidelity. This argument started on Friday night and caused her to essentially not sleep the whole night. Immediately following the ingestion, she called her boyfriend, who then brought her to the emergency room, from where she was subsequently admitted Assess because of an acetaminophen level in the toxic range. safety

Ms. Leia states that she thought that she would die as a result of the ingestion, but denies that she had been premeditating the act prior to yesterday’s argument. She denies having left a suicide note and denies any history of giving away possessions in preparation for death. She says that what she did was “the dumbest thing I’ve ever done” and that she’s “grateful to be alive.” She cannot really say what has changed in their relationship, but says, “no matter what happens, it’s not worth dying for.”


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Ms. Leia denies any past history of suicide attempts, command hallucinations telling her to commit suicide, or any intoxication at the time of the overdose. She notes that, for the past 4 months, she has had, more days than not, a depressed mood related to relationship difficulties, associated with: decreased enjoyment of usually pleasurable activities (e.g., going out with her friends, playing with her 6-year-old son at the beach), terminal insomnia (e.g., waking up at 3 am and not being able to go back to sleep), increased appetite with an unintentional 5-pound weight gain, decreased energy level, feelings of worthlessness, and difficulty concentrating in her job. She admits to some degree of sensitivity to perceived rejection—for example, crying when her friends go somewhere without her, or when her boyfriend is unable to make it for a planned date. Pertinent Past Psychiatric History:

positives and negatives

Ms. Leia reports that when she was around 28 years old, she experienced similar symptoms during the ending of her 5-year marriage to her ex-husband. In retrospect, she believes that her symptoms started within about 1 month following the birth of her son. She saw a psychiatrist (Dr. Qui-Gon Jinn) and took fluoxetine for around 9 months. She reports that the fluoxetine was helpful and stopped this medication because she felt she no longer needed it. She denies any history of manic symptoms (e.g., sustained abnormally elevated mood, racing thoughts, decreased need for sleep, rapid speech, psychomotor agitation, grandiosity, impulsive spending). She admits to sometimes feeling, especially in the past 4 months, a fast heartbeat and lightheadedness associated with feeling “stressed and overwhelmed with everything that’s going on.” These feelings would last less than a minute and would occur no more frequently than every few weeks. She denies any history of feeling any impending sense of doom during these instances, and she denies any worry about feeling these symptoms again in between these instances. She denies any history of repetitive, intrusive thoughts or behaviors. She also denies any history of anxiety in places where she may be under public scrutiny. In terms of any exposure to trauma, she reports having been involved in a car accident when she was 8 years old. Her mother’s car was rear-ended on the freeway by a large truck, resulting in her mother needing to be hospitalized overnight. She says she coped reasonably well with this incident, and she denies any nightmares, flashbacks, or other re-experiencing phenomena related to this incident. She denies any past experience of physical or sexual abuse, and she denies any physical abuse in her current relationship. She admits to drinking socially since age 18 or 19. The last time she had anything to drink was last week, with her friends. She reports only having one or two drinks each time. She denies any history of alcoholic blackouts, hallucinations related to drinking, or withdrawal seizures. She responded negatively to all components of the “CAGE” questionnaire. She denies any other history of substance use.

244


She denies any history of binging (e.g., eating large quantities of food in one sitting, feeling a lack of control over eating) or purging behavior. Past Medical History: Ms. Leia is otherwise healthy, without any chronic health problems. She denies any past history of seizures, major head trauma, or loss of consciousness. However, she notes that she had her wisdom teeth extracted 5 days ago and is still experiencing a significant amount of discomfort. Ms. Leia has been pregnant only once, with her 6-year-old son. She reports a history of irritability and sadness before and during her menstrual periods. She has just started her menstrual period and denies any possibility of current pregnancy. Current medications: acetaminophen/oxycodone. Allergies: ALLERGIC TO PENICILLIN, WHICH CAUSES HIVES. Family History: Ms. Leia believes that her father (65 years old) may have developed depression following a heart attack. He was prescribed an antidepressant, which he took for about 1 year. Her brother also had a history of school difficulties and marijuana abuse as a teenager. She denies any other known family history of depression, completed suicides, other psychiatric disorders, or substance abuse. She has a maternal aunt with a history of hypothyroidism, for which she takes thyroid replacement on an ongoing basis. (OPTIONAL graphic depiction)

65

62

64

Hypothyroidism

35

Heart attack, depression

32

34

School difficulties, Marijuana use 6


245

Developmental and Social History: Ms. Leia grew up in Honolulu. Her parents divorced when she was 3 years of age. She denies that there was any domestic violence around the divorce, only arguing. She recalls being sad when her parents divorced, but admits that she does not really remember details. Her mother raised her. While growing up, she had infrequent contact with her father, who remarried. She reports that she did not get along well with her mother, because her mother was “too strict.” Ms. Leia reports having had difficulties in school, especially in math. She reports having been in special education for a few years. She denies any particular difficulty with concentrating/paying attention in school. She dropped out of 11th grade because she was “sick of school” and wanted to be with her boyfriend at the time. She completed her GED at age 18 years. She would like to return to school sometime and obtain a college degree, perhaps in education or psychology. She has held various jobs: as a cashier, food service provider, and office secretary. Most recently, she has worked as a secretary for a research company for the past 3 years. Ms. Leia had been married to the father of her 6-year-old son for 5 years. Prior to that, she had only been in one long-term serious relationship (from high school). She reports that the marriage ended “mostly because he started getting more and more into drinking and I couldn’t count on him to be around anymore.” There had not been any domestic violence. She has been with her current boyfriend for the past 2 years. She reports that they had been arguing more especially in the past 5 or 6 months, generally over his ongoing friendship with ex-girlfriends. Ms. Leia lives with her 6-year-old son. Her sister and brother help to provide childcare while she is at work. Her son stays with his father (who shares legal custody) during the weekends and was not with her during the time of the ingestion. She states that she misses her son when he is at his father’s place. Her ex-husband pays child support, but still notes that it’s “hard to make ends meet” especially now that her son has started private school at their local church. She currently sees her mother at least once per week and talks to her father around once every few months. She feels close to her older sister and sees her frequently during the week. Her sister has come to visit her in the hospital and has been supportive. Ms. Leia is active in church and reports that her friends from church are also very supportive. When she stopped seeing Dr. Qui-Gon Jinn, she had hoped she could stay emotionally well if she prayed and talked regularly to her pastor. Ms. Leia denies having any access to firearms or other weapons. Review of Systems: Constitutional: History of weight gain, decreased energy level. Eyes: Negative.

246


ENT: History of recent extraction of wisdom teeth. CV: For the past 4 months, occasional fast heartbeat and lightheadedness when she is anxious. No history of any chest pain, shortness of breath, or other cardiac symptoms. Respiratory: Negative. GI: Some nausea following overdose; otherwise negative. GU: Regular urinary pattern, no discharge. Recently started menses. Musculoskeletal: Negative. Skin: Negative. Neuro: Negative. No headaches, speech/gait abnormalities, weakness, numbness, paresthesias. Psych: Depressed mood, suicidal ideation (see HPI). Endocrine: No known history of thyroid disease. Endorses some history of feeling cold easily, even when others feel warm. All others: Negative. Physical examination: Constitutional: Well developed, well nourished, no acute distress. Normal body habitus, no obvious deformities. Adequate groom; dressed in hospital gown. Vital signs: temperature 98.6 ◦ F, pulse 72 per minute, BP 110/70, RR 18, SaO2 100 % in RA. Eyes: Pupils 3 mm, reactive. Musculoskeletal: No abnormal movements, rigidity, or tremor. Appears to have normal use of all extremities. Skin: Warm and dry, no diaphoresis. Mental Status Examination: Eye contact: Good. Cooperation with interview: Cooperated well. Motor activity: No psychomotor agitation or retardation. Speech: Normal rate, volume, clarity, and amount. Mood: “Sad and depressed, not my usual self.” Affect: Congruent, depressed, and tearful at appropriate points of the interview (e.g., discussing recent relationship difficulties, discussing how she feels when her son is not there). Affect brightened somewhat upon discussing her son’s achievements in school. Thought process: Linear, goal-directed. Thought content: No delusions or paranoid ideations. Conveys future orientation: return to work, see her son as soon as she is able. Perceptions: Denies any auditory or visual hallucinations. Does not appear to be responding to hallucinations. Orientation: Oriented to person, place, time, and situation. Attention/concentration: Attended well to the interview and was able to spell “world” forward and backward without difficulty.


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Memory: Able to register 3/3 unrelated words without difficulty and to remember 3/3 after 5 minutes. Able to name the past 5 US presidents in reverse chronological order. Knowledge: Good fund. Abstractions: Able to note similarities (apple/orange, table/chair, opera/painting) appropriately. Judgment: Fair. She states that, if she were ever feeling suicidal again, she would call her sister or someone else who was able to assist her. Insight: Fair. Able to recognize that her suicidal thoughts may be related to a recurrence of depression and that she may benefit from psychiatric care once again. Suicidal ideations: Denies, even with repeated questioning. Verbally agrees not to do anything to harm herself in the hospital and agrees to inform staff if she were to feel distressed again. Homicidal ideations: Denies. Laboratory Studies (on Admission): Urine toxicology: Positive for opiates, otherwise negative. Electrocardiogram: Normal sinus rhythm, normal EKG. Acetaminophen level: Borderline toxic range. Acetylsalicylic acid level: negative. CBC with differential: All values within normal range. Comprehensive metabolic profile: All values within normal range, including LFTs. PT/PTT: Within normal range. Serum HCG: Negative. Formulation: In summary, Ms. Leia is a 34-year-old female admitted to the hospital for a potentially toxic intentional acetaminophen overdose and a history of depression. Relevant biological factors include: a possible genetic predisposition to depression (family history), recent physical discomfort (status-post tooth extraction, sleep deprivation) just prior to the suicide attempt, and possible hormonal influences (history of postpartum onset of depression, history of mood changes before and during menses, which she is currently having). Other, less prominent (though possibly still relevant) factors include: current use of a pain medication that could affect mood (oxycodone) and infrequent use of alcohol (none in the past few days). Relevant psychological factors include: the recent argument with her boyfriend, and possibly the fact that her son was not with her at the time of the suicide attempt (as the more recent, precipitating factors); a past history of losses and transitions, including her parents’ divorce, a less-than-optimal relationship with the parent who raised her, and the breakup of a previous marriage; other factors (e.g., school difficulties) that could have led to a loss of self-esteem and predisposed her to depression; and what she describes as an increased sensitivity to perceived rejection. Also,

248


she is at a stage in life where she may be hoping for more stability in her relationship/family life and financial situation than she currently has, and this may be an additional factor contributing to depression. Relevant social/cultural/spiritual factors include: ongoing financial stress and working in the single parent role. She describes receiving emotional and other support from siblings and friends. She has maintained a stable job for the past few years. Her beliefs about the nature and treatment of depression may be influenced by her religious orientation. Her religious involvement is positive influence in her life. Depicted graphically (with treatment interventions enclosed in ovals)—ALSO OPTIONAL: Supportive therapy Biological

Social/cultural

Psychological Loss of self-esteem

Suboptimal relationship with parent Didnít finish school

Genetic predisposition SSRI Depression Sleep deprivation Loss of coping ability

Hospital rest

Expectation for relationship, financial stability at life stage

Pain s/p tooth extraction

Parents’ divorce Own divorce

Financially hard Single parent

Argument with boyfriend

Son not with her

Alternatives, Crisis hotline

Loneliness Suicide attempt Sensitivity to rejection

Enlist help from friends, family, church

Differential Diagnoses: On Axis I: 1. Major Depressive Disorder, Recurrent: patient meets DSM-IV criteria for this diagnosis. She also may meet the criteria for atypical features. 2. Bipolar II Disorder: a consideration given the history of recurrent major depressive episodes; however, no definite history of manic symptoms endorsed in this interview. 3. Adjustment Disorder with Depressed Mood: with the stressors being the relationship difficulties; however, because she meets the criteria for a Major Depressive Disorder, the latter diagnosis would supersede.


249

4. Panic Disorder: patient describes a history of fast heartbeat and lightheadedness; however, does not meet full criteria for panic attacks, and these symptoms occurred only in the context of what appears to be a major depressive episode. 5. Substance Abuse (Alcohol) and Substance-Induced Mood Disorder: based on the history provided, would not meet criteria for a substance use disorder; collateral information would be helpful in ruling out this possibility. 6. Premenstrual Dysphoric Disorder: patient describes some symptoms around menses that may be consistent with this condition; however, it is unclear that they were absent following menses and not merely an exacerbation of what is likely a Major Depressive Disorder. 7. Mood Disorder Due to a General Medical Condition (with depression): thyroid disorder (given family history) and primary heart condition (with anxiety symptoms) should be considered. 8. Mathematics or other Learning Disorder: given history of school difficulties and special education. On Axis II: 1. Borderline Personality Traits: with sensitivity to abandonment; however, it is not clear that her history is necessarily characterized by “a pattern of unstable and intense relationships . . .” or “recurrent” suicidal behavior. 2. Dependent Personality Traits: discomfort with being alone; however, it is also not clear that criteria are met for this personality disorder. On Axis III: 1. Status: post-overdose (acetaminophen, hydrocodone, ibuprofen) 2. Status: post-tooth extraction 3. PENICILLIN ALLERGY (important to recall, though not necessarily directly relevant to current psychiatric status) 4. Possible thyroid disorder: family history of thyroid disorder; history of cold intolerance. 5. Possible cardiac arrhythmia: given history of fast heartbeat, lightheadedness; however, the timing of these symptoms seemed to coincide with the episode of depression, and the EKG done on admission was negative. Working diagnoses: Axis I Major Depressive Disorder, Recurrent Learning Disorder Not Otherwise Specified (Provisional) Axis II Deferred Axis III Status-post overdose Status-post tooth extraction with pain Axis IV Primary support, relationship difficulties, financial stressors Axis V Current GAF = 50; Highest GAF in past year = 75

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Treatment Plan: Treatment setting: Ms. Leia should remain in the hospital because she needs general medical treatment for the overdose. A standard hospital suicide risk assessment form has been completed, and orders have been written appropriate to her level of suicide risk, with removal of potentially injurious objects and frequent nursing checks. Other specific interventions are as follows:

Biological/medical

Psychological

Social

Additional information

1. Review past records from previous treating psychiatrist, with attention to medication issues 2. Consider checking a TSH

1. With patient’s permission, speak with family members for collateral information 2. Assess whether son (minor) is under appropriate care currently

Treatment

1. Medical treatment of overdose as per general medical team 2. Patient may be a candidate for re-starting of SSRI, such as fluoxetine, which had been helpful in the past. Consider monitoring response using standard rating scales for depression 3. Encourage adequate rest while in the hospital

1. Meet again with patient to clarify diagnostic issues as noted above 2. Review past records from treating psychiatrist 3. Consider rating scales for depression and other mood disorders 1. Individual supportive psychotherapy to be provided during medical hospitalization, with focus on psychoeducation about depression and discussion of feelings about current and past stressors 2. In the longer term, may be a candidate for cognitivebehavioral psychotherapy (e.g., to address feelings of worthlessness, rejection) or interpersonal psychotherapy (e.g., to address role transitions, losses)

1. Enlist support from family members and friends where appropriate 2. Disposition (e.g., discharge to outpatient care versus psychiatric hospitalization) to be determined during follow-up visits


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(Continued) Patient education

Biological/medical

Psychological

Social

1. Education about the alternatives to and potential benefits/risks of treatment with SSRI 2. Advise patient to avoid drinking alcohol at this time, as it may impair judgment and render her more vulnerable to self-destructive acts

1. Provide information on crisis phone numbers 2. Provide information on the importance of depression treatment, including ongoing medical follow-up

With patient’s permission, enlist family’s help in insuring safety in the environment (e.g., no large bottles of dangerous medications) and in encouraging patient to make use of available resources

Prognosis: Ms. Leia’s prognosis at this point would seem to be fair to good. One important risk factor is current relationship instability. However, from the standpoint of completed suicide risk, she has a fairly favorable demographic profile (young, female, employed); no past history of suicide attempts; and no apparent substance abuse problem. From the standpoint of major depression, she has a history of good response to SSRI treatment in the past. Her social supports and church involvement may also be factors that weigh in her favor.

Bibliography American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Washington, DC: American Psychiatric Press; 2000. Guerrero APS, Hishinuma ES, Serrano AC, Ahmed I. Use of the “Mechanistic case diagramming” technique to teach the bio-psycho-social-cultural formulation to psychiatric clerks. Academic Psychiatry 2003; 27: 88–92. Guerrero APS, Ling CYL, Ahmed I, Takeshita J, Bell CK. Development of a structured module to teach psychiatric interviewing competencies to medical students. Focus on Health Professional Education: A Multidisciplinary Journal (in press).

Chapter 18

Disorders of Childhood Erika Ryst and Jeremy Matuszak

Childhood is a time of great vulnerability to psychiatric problems. This chapter will introduce three cases that will highlight some of the most common disorders and treatments. At the end of this chapter, the reader will be able to 1. Describe the fundamental differences between a child and an adult psychiatric evaluation 2. Differentiate between the diagnostic criteria for adult and childhood psychiatric illnesses 3. Describe the epidemiology, phenomenology, etiology, and treatment for major childhood psychiatric diagnoses

Case Vignette 18.1.1 Presenting Situation: Sam A mother brings in Sam, her 7-year-old boy, to you for a child psychiatric evaluation. She tells you that she is here at the insistence of the boy’s classroom teacher, who notices an inability to sit still, decreased academic performance compared to his age-mates, and generally disruptive classroom behavior. These concerns have been going on for several months since the beginning of the school year. The mother seems a bit irritated that the school is requesting your evaluation. Sam is a cute, brown-haired boy with normal-appearing features. He gets up frequently from his seat but tends to hover in the immediate vicinity of his mother.


E. Ryst Assistant Professor of Psychiatry, University of Nevada School of Medicine


253

254

E. Ryst, J. Matuszak

Discussion The psychiatric evaluation of a child differs from that of an adult in a number of fundamental ways. To start, children rarely present to your office with a chief complaint or treatment agenda. Rather, it is the parents/caregivers that will provide the reason for referral and evaluation. The process of evaluating a child/adolescent necessitates taking histories from not only the child, but the caregiver and school environments as well. When interviewing the child, it is important to communicate in a way that is appropriate to developmental level. The child may not be able to say in words what is wrong, but the observation of his behavior may give clues as to the diagnosis. A thorough chronological history including conception, childbirth, physical development/medical history, school functioning, and emotional development must be obtained to properly formulate the case. Special attention must be paid to any history of trauma (emotional, physical, or sexual) that may have precipitated the child’s symptoms. Generating a differential diagnosis requires both time and caution, as symptoms of different disorders may present in the same way (for example, irritability could reflect a biological mood disorder or an environmental stressor such as child abuse). Therefore, the DSM-IV-TR, while a useful diagnostic guideline, may not be as applicable to children as it is to adults. Differential diagnosis at this time is broad, but includes: attention deficit hyperactivity disorder (ADHD), pervasive developmental disorder (PDD), mental retardation (MR) or learning disorder, mood or anxiety disorder, environmental causes (e.g., being bullied at school), and oppositional defiant disorder (ODD).

Case Vignette 18.1.2 Continuation Sam’s school sends evaluation results. He has a high IQ with academic performance in the expected range for age. However, on the Weschler Intelligence Scale for Children (WISC), the working memory and attention scales show current impairment. A WISC performed 1 year ago showed a slightly higher IQ with attention and memory in the average range. During your classroom observation, you observe that Sam is highly distractible, particularly in high-stimulation situations. He jumps at loud noises and then has trouble returning to his schoolwork. At times, he gazes out of the window and seems to be lost in his own world. You are able to speak with Sam’s first-grade teacher (he is now in the second grade) and she indicates that none of the current behavioral and cognitive problems existed 1 year ago.


18 Disorders of Childhood

255

This new information should now narrow the differential diagnosis. ADHD has now moved lower in the differential as these symptoms were not present before age 7. Additionally, it is now evident that the changes in attention and cognition are of a more acute onset (i.e.,

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